Unique Clinical Scenarios Research Articles

Kidney Replacement Therapies in Advanced Heart Failure - Timing, Modalities, and Clinical Considerations.

Acute kidney dysfunction is commonly encountered in advanced heart failure and carries significant prognostic implications, often leading to poorer outcomes and increased mortality. It can alter the course of decision making for left ventricular assist device (LVAD) and cardiac transplantation candidacy. Kidney replacement therapies (KRT) offer a critical intervention in this context but require careful consideration of timing, various types of KRT modalities, individual patient preferences and circumstances. This review discusses the intricacies of KRT in advanced heart failure, examining how to optimize timing and choose among the various KRT modalities. It also provides a detailed discussion on the unique clinical scenarios that clinicians may face when treating this vulnerable patient group.

The impact of online CME on clinicians’ ability to utilize immunotherapy in unique populations of patients with NSCLC.

e21004 Background: Immunotherapy (IO) has become a standard of care in the management of advanced non-small cell lung cancer (NSCLC). However, treatment with IO-based regimens may not always be straightforward, particularly in unique clinical scenarios and patient populations. As such, members of the multidisciplinary care team, including oncologists and pulmonologists, may lack experience in utilizing IO in these instances. The objective of this study was to assess the educational impact of a series of continuing medical education (CME) activities on the knowledge, competence, and confidence of oncologists and pulmonologists with respect to recognizing strategies that facilitate the safe and effective use of IO in patients with advanced NSCLC. Methods: The educational analysis consisted of 2 online, CME-certified activities. Educational impact was assessed with repeated pre-/post-education including multiple choice knowledge/competence questions and 5-point Likert scale confidence questions. Data from all oncologists and pulmonologists who completed pre- and/or post-education assessments were aggregated across activities and stratified by learning theme. Relative changes in percentage of correct responses and clinicians who were confident (value of 4 or 5) were used to measure improvement in knowledge, competence, and confidence. A McNemar’s test assessed significant levels of changes reported with P values <.05 considered statistically significant. The first activity in the analysis launched October 2023 and the last launched November 2023; data were collected until January 2024. Results: The educational series resulted in improvements in oncologists’ (N=119) and pulmonologists’ (N=49) knowledge, competence, and confidence after education. Conclusions: This analysis demonstrates that oncologists’ and pulmonologists’ knowledge, competence, and confidence regarding the safe and effective use of IO in patients with advanced NSCLC improved after education. Despite these improvements, additional educational activities are needed to address residual gaps and further increase clinicians’ ability in these dynamic and challenging clinical settings. [Table: see text]

Sodium bicarbonate and intubation in severe diabetic ketoacidosis: are we too quick to dismiss them?

Management of diabetic ketoacidosis (DKA) has internationally established guidelines. However, management of severe, refractory DKA with multiple contributors to acidosis, and management of DKA in patients with altered mentation, remain ambiguous. Use of sodium bicarbonate and intubation in DKA are unpopular treatment practices, but warrant consideration in these unique clinical scenarios. This paper describes a 61-year-old Sri Lankan female who presented with severe DKA, seizures and altered level of consciousness. In her case, the acidosis was secondary to DKA, hyperlactatemia, hyperchloraemic acidosis and acute kidney injury (AKI). Intravenous sodium bicarbonate was used in the management of acidosis. She was intubated due to altered level of consciousness with inadequate respiratory drive to compensate for metabolic acidosis. The outcome in her case was favorable. Intravenous sodium bicarbonate in DKA should be considered for patients with severe, refractory acidosis with hemodynamic instability, hyperkalemia and compounding acidosis due to normal anion gap acidosis or AKI. Intubation should be considered for patients with obtunded mentation unable to achieve respiratory compensation and obtunded mentation where reversal of DKA is unlikely to improve consciousness. Both strategies should be personalized with consideration of individual risk vs benefit.

Preservation of neurologic function in the setting of penetrating-knife spinal cord injury with dural involvement and concurrent lung injury

Introduction Penetrating spinal cord injuries present unique clinical scenarios with high variability in presentation and management. These injuries are rare, accounting for 0.8% of annual penetrating spine injuries in the United States, with knives being the most common penetrating object. Retention of the knife blade further complicates management, with greater risk of infection and progressive neurologic injury. Given the rarity and variability of such injuries, preferred management for penetrating-knife spinal cord injuries (PKSCI), especially those with retained knife blades, remains contested. Furthermore, the management of PKSCI with concurrent lung injury is poorly described within the literature. Case Report Here we discuss a unique case of a neurologically intact adult male who suffered a large lower thoracic PKSCI with complete dural transection and lung involvement. The patient arrived with the blade in situ while maintaining full neurologic function. Emergent imaging revealed the blade trajectory passing through the T8 lamina exiting the spinal canal at the costovertebral junction with involvement of the lung parenchyma and associated pneumorrhachis and pneumothorax. The patient was brought to the operating room where the blade was removed under direct visualization, the dura was repaired, and pneumothorax was stabilized. Conclusion We describe in this case the choice of imaging, method of blade removal, cerebrospinal fluid leak management, dural repair, and concurrent lung injury management that afforded a favorable, ASIA class E outcome with complete preservation of neurologic function.

An Ethical Framework for Allergy and Immunology

Ethical dilemmas routinely occur in the clinical practice of allergy and immunology. These ethical questions stem from the range of conditions and the different populations cared for by Allergists/Immunologists. Hence, medical ethics is not an esoteric concept, but a practical skill physicians exercise regularly. Moreover, an ethics-centered approach may improve patient safety and outcomes. This article will describe key principles of bioethics and illustrate an ethical framework that physicians can use in their conversations with patients. Utilization of this ethical framework is demonstrated through applying it to four unique clinical scenarios encountered by Allergists/Immunologists from different practice settings. The ethical framework for allergy and immunology is a technique to navigate ethically complex decisions that arise in routine clinical practice.

Flexible, Biodegradable, and Wireless Magnetoelectric Paper for Simple In Situ Personalization of Bioelectric Implants.

Bioelectronic implants delivering electrical stimulation offer an attractive alternative to traditional pharmaceuticals in electrotherapy. However, achieving simple, rapid, and cost-effective personalization of these implants for customized treatment in unique clinical and physical scenarios presents a substantial challenge. This challenge is further compounded by the need to ensure safety and minimal invasiveness, requiring essential attributes such as flexibility, biocompatibility, lightness, biodegradability, and wireless stimulation capability. Here, a flexible, biodegradable bioelectronic paper with homogeneously distributed wireless stimulation functionality for simple personalization of bioelectronic implants is introduced. The bioelectronic paper synergistically combines i) lead-free magnetoelectric nanoparticles (MENs) that facilitate electrical stimulation in response to external magnetic field and ii) flexible and biodegradable nanofibers (NFs) that enable localization of MENs for high-selectivity stimulation, oxygen/nutrient permeation, cell orientation modulation, and biodegradation rate control. The effectiveness of wireless electrical stimulation in vitro through enhanced neuronal differentiation of neuron-like PC12 cells and the controllability of their microstructural orientation are shown. Also, scalability, design flexibility, and rapid customizability of the bioelectronic paper are shown by creating various 3D macrostructures using simple paper crafting techniques such as cutting and folding. This platform holds promise for simple and rapid personalization of temporary bioelectronic implants for minimally invasive wireless stimulation therapies.

Malignant masquerade: Clinician dilemma revisited

Mimesis is a Greek word that means to imitate, while the word masquerade means pretending to be something or someone that he/she is not. In this case series of four cases pertaining to different organ subsets, we discuss and highlight the benign medical conditions, which pretended as neoplastic both clinically and radiologically preoperatively; however, the postoperatively histopathological report yielded surprising results. Though lots of literature on a malignant masquerade is available, there is a paucity of data on case series discussing the different subset organ involvement. These unique clinical scenarios also emphasize the fact that it is incorrect to judge a book by its cover. We would like to summarize our humbling experience in the word of William Osler “medicine is the science of uncertainty and art of probability.”

The Nexus of Hyperparathyroidism and Thyroid Carcinoma: Insights into Pathogenesis and Diagnostic Challenges-A Narrative Review.

This review investigates the intricate relationship between hyperparathyroidism (HPT) and thyroid carcinoma (TC), aiming to elucidate their coexistence, potential pathogenetic mechanisms, and clinical implications. A systematic search strategy, employing the MeSH terms 'Hyperparathyroidism' and 'Thyroid Carcinoma', spanned publications from 2013 to 2023 across the PubMed, Web of Science, and Scopus databases. Fifteen selected articles were analyzed. Studies unanimously confirm the notable association between primary hyperparathyroidism (PHPT) and thyroid nodules/cancer, with incidences ranging from 2.8% to 47.1%. Key findings reveal a predilection for papillary thyroid carcinoma (PTC) in this association, showcasing varying tumor characteristics and gender disparities. Lower preoperative serum parathyroid hormone (PTH) levels are a potential risk factor for thyroid cancer in PHPT patients. Diverse surgical approaches and tumor characteristics between PHPT and secondary hyperparathyroidism (SHPT) cases were noted. Moreover, this review underscores the scarcity of definitive guidelines in managing concurrent PHPT and thyroid conditions, advocating for comprehensive assessments to enhance diagnostic accuracy and refine therapeutic interventions. Rare coincidental associations, as highlighted by case reports, shed light on unique clinical scenarios. In essence, this review amalgamates evidence to deepen the understanding of the interplay between HPT and TC, emphasizing the need for further research to elucidate underlying mechanisms and guide clinical management.

Treatment of serpiginous choroiditis with sub-tenon triamcinolone in conjunction with systemic steroids case report.

To report two cases of serpiginous choroiditis which were treated with sub-Tenon's triamcinolone in conjunction with systemic steroids to control acute and chronic disease progression. Increased success of disease remission has been postulated for sub-Tenon's triamcinolone therapy in conjunct with systemic steroids. Retrospective chart review of two serpiginous choroiditis patients who presented at an eye center. Both patients received sub-Tenon's triamcinolone and systemic steroids. Visual acuity and disease course are reported. Both cases of serpiginous choroiditis received sub-Tenon's triamcinolone on presentation and were hospitalized for intravenous corticosteroids and systemic work up. The first patient had been on oral corticosteroids before presentation. Both patients reported same day visual improvement after sub-Tenon's triamcinolone was administered. These two case reports describe unique clinical scenarios in which sub-Tenon's triamcinolone was used in both the acute and chronic phases of serpiginous choroiditis. Local steroid therapy can be a useful adjunctive therapy when systemic steroids are delayed, contraindicated or intolerable.

The community of inquiry framework for virtual team-to-team debriefings during interprofessional trauma simulations.

PurposePsychological safety is key to effective debriefing and learning. The COVID-19 pandemic necessitated rapid adaption of simulation events to virtual/hybrid platforms. We sought to determine the effect of utilizing the Community of Inquiry framework (CoI) for debriefing virtually connecting interprofessional learner teams on the psychological safety experienced during trauma simulations.MethodsGeneral surgery (GSR), emergency medicine (EMR) residents, trauma nurses/nurse practitioners and medical students participated in multiple simulation events designed to improve teamwork and leadership skills. Pre-course materials were provided before the event for learners to prepare. Briefings delineating expectations emphasized importance of and strategies employed to achieve psychological safety. Four unique clinical scenarios were run for each simulation event, with a debrief after each scenario. Virtual team-to-team debriefings were structured using the Community of Inquiry (CoI) conceptual framework. All learners completed pre-/post-assessments utilizing Inter-professional Collaborative Competencies Attainment Survey (ICCAS).ResultsTwenty-five learners participated (13 GSR, 5 EMR, 3 medical students, 2 trauma APRNs and 2 trauma RNs). Learner assessment found 88% (22) “agreed”/”strongly agreed” that virtual team-to-team debriefing had social, cognitive and educator presence per the CoI domains. However, one GSR and two nurse learners “strongly disagreed” with these statements. Most learners felt the debriefing was effective and safe. All participants “strongly agreed”/“agreed” the simulation achieved ICCAS competencies.ConclusionsDebriefings utilizing a virtual platform are challenging with multiple barriers to ensuring psychological safety and efficacy. By structuring debriefings using the CoI framework we demonstrate they can be effective for most learners. However, educators should recognize the implications of social identity theory, particularly the effects of hierarchy, on comfort level of learners. Developing strategies to optimize virtual simulation learning environments is essential as this valuable pedagogy persists during and beyond the COVID-19 pandemic.

AAOS Appropriate Use Criteria: Management of Rotator Cuff Pathology.

AAOS Appropriate Use Criteria: Management of Rotator Cuff Pathology.

Clinical and Pharmacologic Differences of CDK4/6 Inhibitors in Breast Cancer.

Targeted therapies such as Cyclin Dependent Kinase 4 and 6 (CDK 4/6) inhibitors have improved the prognosis of metastatic hormone receptor (HR) positive breast cancer by combating the resistance seen with traditional endocrine therapy. The three approved agents currently in the market are palbociclib, ribociclib and abemaciclib. Besides the overall similarities associated with CDK4/6 inhibition, there are differences between the three approved agents that may explain the differences noted in unique clinical scenarios- monotherapy, patients with brain metastases or use in the adjuvant setting. This review article will explore the preclinical and pharmacological differences between the three agents and help understand the benefits seen with these agents in certain subgroups of patients with metastatic HR positive breast cancer.

A call for transplant stewardship: The need for expanded evidence-based evaluation of induction and biologic-based cost-saving strategies in kidney transplantation and beyond.

Rising expenditures threaten healthcare sustainability. While transplant programs are typically considered profitable, transplant medications are expensive and frequently targeted for cost savings. This review aims to summarize available literature supporting cost-containment strategies used in solid organ transplant. Despite widespread use of these tactics, we found the available evidence to be fairly low quality. Strategies mainly focus on induction, particularly rabbit antithymocyte globulin (rATG), given its significant cost and the lack of consensus surrounding dosing. While there is higher-quality evidence for high single-dose rATG, and dose-rounding protocols to reduce waste are likely low risk, more aggressive strategies, such as dosing rATG by CD3+ target-attainment or on ideal-body-weight, have less robust support and did not always attain similar efficacy outcomes. Extrapolation of induction dosing strategies to rejection treatment is not supported by any currently available literature. Cost-saving strategies for supportive therapies, such as IVIG and rituximab also have minimal literature support. Deferral of high-cost agents to the outpatient arena is associated with minimal risk and increases reimbursement, although may increase complexity and cost-burden for patients and infusion centers. The available evidence highlights the need for evaluation of unique patient-specific clinical scenarios and optimization of therapies, rather than simple blanket application of cost-saving initiatives in the transplant population.

Clinical Review of Proton Therapy in the Treatment of Unilateral Head and Neck Cancers.

Radiotherapy is a common treatment modality in the management of head and neck malignancies. In select clinical scenarios of well-lateralized tumors, radiotherapy can be delivered to the primary tumor or tumor bed and the ipsilateral nodal regions, while intentional irradiation of the contralateral neck is omitted. Proton beam therapy is an advanced radiotherapy modality that allows for the elimination of exit-dose through nontarget tissues such as the oral cavity. This dosimetric advantage is apt for unilateral treatments. By eliminating excess dose to midline and contralateral organs at risk and conforming dose around complex anatomy, proton beam therapy can reduce the risk of iatrogenic toxicities. Currently, there is no level I evidence comparing proton beam therapy to conventional photon radiation modalities for unilateral head and neck cancers. However, a growing body of retrospective and prospective evidence is now available describing the dosimetric and clinical advantages of proton beam therapy. Subsequently, the intent of this clinical review is to summarize the current evidence supporting the use of proton beam therapy in unilateral irradiation of head and neck cancers, including evaluation of disease site-specific evidence, unique challenging clinical scenarios, and ongoing clinical trials.

Management of BTK Inhibitor Associated Adverse Events: Current Practice Trends Among Healthcare Providers and Concordance with Expert Recommendations

Introduction: The advent of BTK inhibitors (BTKi; ibrutinib, acalabrutinib, zanubrutinib) has dramatically improved outcomes for many patients with B-cell malignancies including CLL/SLL, MCL, WM, and MZL. To ensure optimal patient outcomes with BTKi therapy, it is essential to maintain both ongoing therapy and patient quality of life. These dual goals require prompt recognition and management of the unique adverse events (AEs) associated with BTKi therapy. An online Interactive Decision Support Tool was developed to provide healthcare providers (HCPs) with case specific guidance on managing BTKi AEs (available at: www.clinicaloptions.com/BTKiTool). Here, we report HCP practice trend data for the management of various BTKi AEs collected with this online tool compared with recommendations from a panel of experts. Methods: The online tool was developed with input from 5 experts who provided BTKi AE management recommendations for specific patient scenarios. The online tool captured 164 unique clinical scenarios based on criteria including disease type, BTKi used, and the type and severity of the BTKi AE. To use the online tool, HCPs enter information about their patient case and their planned management strategy. The HCPs were then shown the management recommendation from the 5 experts for that specific BTKi AE scenario. After viewing the expert management recommendation, HCPs were asked if it had an impact on their intended management approach. Results: Between September 2019 and July 2020, 754 unique case scenarios were entered into the BTKi AE tool, with 319 cases related to a specific BTKi AE, by 432 HCPs. Of HCPs who answered the optional demographics questions (n = 96), 65% of cases were entered by clinicians who treat ≤ 10 patients/year with BTKi and 51% of cases entered were for specific patients in their clinical practice. Most cases entered in the tool were for patients with CLL (69%) followed by MCL cases (15%). Cases involving ibrutinib treatment were most common in this analysis (82% of cases) with acalabrutinib treatment entered for the remaining 18% of cases. Zanubrutinib was not yet approved when this tool was created and therefore was not included as a BTKi option. The most common AEs selected by HCPs using the tool regardless of BTKi therapy were atrial fibrillation, bruising or bleeding, and diarrhea [Figure]. For patient scenarios treated with acalabrutinib, HCPs also frequently selected headache (24%) as an AE of interest [Figure]. Overall, the planned BTKi AE management strategy of HCPs for mild to moderate AEs matched the expert recommendations in 56% of cases with ibrutinib treatment and 79% with acalabrutinib treatment. There was lower concordance between HCPs and experts for the management of grade 3/4 events with either ibrutinib (42%; P < .0001) or acalabrutinib (36%; P < .0001). For example, for patient cases with grade 3/4 atrial fibrillation (n = 49), only 39% of HCPs would hold therapy whereas 41% indicated that they would continue therapy and 14% were unsure how to manage the AE. For HCPs who differed from expert recommendations, only 42% of respondents who entered mild to moderate AEs indicated that the expert recommendations provided by the tool changed their management plan, but 81% of respondents who entered grade 3/4 events would change their management plan. Conclusions: These data suggest that management of BTKi AEs by HCPs often diverges from evidence-based expert recommendations, especially grade 3/4 AEs. Use of an online tool providing easy access to BTKi AE management recommendations may improve patient care and safety. A detailed analysis of the tool, including case entries and planned management vs expert recommendations will be presented. Figure Disclosures Awan: Blueprint medicines: Consultancy; Celgene: Consultancy; Pharmacyclics: Consultancy; Janssen: Consultancy; Abbvie: Consultancy; Astrazeneca: Consultancy; Sunesis: Consultancy; Karyopharm: Consultancy; MEI Pharma: Consultancy; Genentech: Consultancy; Gilead Sciences: Consultancy; Kite Pharma: Consultancy; Dava Oncology: Consultancy. Leonard:MEI Pharma: Consultancy; Bayer: Consultancy; Gilead/Kite: Consultancy; Karyopharm: Consultancy; GenMab: Consultancy; BMS/Celgene: Consultancy; Roche/Genentech: Consultancy; Epizyme: Consultancy; Sutro: Consultancy; Miltenyi: Consultancy; AstraZeneca: Consultancy; Regeneron: Consultancy; ADC Therapeutics: Consultancy. Vose:AbbVie: Consultancy, Honoraria; Kite, a Gilead Company: Honoraria, Research Funding; Incyte: Research Funding; Novartis: Research Funding; Seattle Genetics: Research Funding; Epizyme: Honoraria, Research Funding; Karyopharm Therapeutics: Consultancy, Honoraria; Allogene: Honoraria; Bristol-Myers Squibb: Research Funding; Miltenyi Biotec: Honoraria; Wugen: Honoraria; Roche/Genetech: Consultancy, Honoraria, Other; Celgene: Honoraria; Loxo: Consultancy, Honoraria, Research Funding; Verastem: Consultancy, Honoraria; Janssen: Honoraria; AstraZeneca: Consultancy, Honoraria, Research Funding. Flowers:Denovo Biopharma: Consultancy; Kite: Research Funding; Celgene: Consultancy, Research Funding; Gilead: Consultancy, Research Funding; OptumRx: Consultancy; Karyopharm: Consultancy; Pharmacyclics/Janssen: Consultancy; Spectrum: Consultancy; Acerta: Research Funding; Millennium/Takeda: Consultancy, Research Funding; TG Therapeutics: Research Funding; Burroughs Wellcome Fund: Research Funding; Eastern Cooperative Oncology Group: Research Funding; National Cancer Institute: Research Funding; V Foundation: Research Funding; Cancer Prevention and Research Institute of Texas: Research Funding; Genentech, Inc./F. Hoffmann-La Roche Ltd: Consultancy, Research Funding; AbbVie: Consultancy, Research Funding; BeiGene: Consultancy; Leukemia and Lymphoma Society: Membership on an entity's Board of Directors or advisory committees; Bayer: Consultancy.

Case Report: An Atypical Innervation to the Gluteus Maximus by the Sciatic Nerve and its Clinical Implications

Anatomical variations, concerning the gluteus maximus (GM), are uncommon and of clinical importance. Usually, the GM is innervated by Inferior Gluteal Nerve (IGN), a branch of the sacral plexus arising from the ventral rami of L5 to S2. An unusual innervation was identified in routine cadaveric dissection in an elderly Puerto Rican female. Here, both the left and right GM were innervated by their corresponding IGN, yet both had an additional innervation by the Sciatic Nerve (SN). The bilateral SN branch to the GM was located proximally, when compared to the IGN, and emerged by the inferior border of the Piriformis muscle. In literature, there have been previous studies reporting multiple forms of innervations to the GM by the SN. Nevertheless, in these cases, the IGN was absent, and this anomaly was usually unilateral.The implications of this variation encompass both clinical and surgical correlations with respect to patient care. Regarding clinical aspects, patients with this dual variation to the GM can present with unique clinical scenarios which might be easily misdiagnosed. For instance, pain caused by inflammation of the GM in these patients might be misinterpreted and associated to pain felt in other conditions related to the SN, such as sciatica and piriformis syndrome. Likewise, women considering surgical intervention in this area might be at a higher risk of an iatrogenic nerve injury due to the anomalous SN branch to the GM.Thus, goal of this case report is to highlight the clinical and surgical implications of this finding based on the variant anatomy of the gluteal region. Physicians need to be aware of the existence of this variation. This might clarify the puzzling clinical manifestations of patients with the latter as well as avoid iatrogenic nerve injuries during surgical interventions.

The management of elderly patients with brain metastases from breast cancer.

Breast cancer is the most common type of malignancy diagnosed in women worldwide, as well as the second most common cause of metastatic brain lesions in the general population. Most breast cancer patients enrolled in clinical trials are relatively young. Elderly patients, as compared to their younger counterparts, pose unique clinical scenarios because there is limited data in this subpopulation of patients with brain metastases from breast cancer. Elderly patients are commonly treated with less aggressive therapies, perhaps due to comorbid conditions, patient preference, or other age-related concerns. Current treatment modalities offering more favorable toxicity profiles, along with more accurate prognosis, can represent an opportunity to offer improved care for this patient population. From the few efforts studying brain metastatic disease in the elderly, it is be possible to infer that age alone may not play an independent role in treatment selection and that a patient-specific evaluation and ultimate clinical judgment should guide clinical decision-making.

Utility of point-of-care ultrasound in the pediatric intensive care unit

For critically ill patients, point-of-care ultrasound (POCUS) has been rapidly adopted for use in emergency departments and critical care units for diagnostic purposes and to guide decision making. We present two unique clinical scenarios in the Pediatric Intensive Care Unit (PICU), one in which ultrasound was used as a diagnostic tool to identify pulmonary edema, and the other in which ultrasound was used to facilitate placement of a naso-duodenal tube for enteral feeding. The potential role of POCUS in the PICU is presented and its utility in these two unique clinical scenarios discussed. Although, many cases will still require further radiological tests, The success of POCUS lies in immediate diagnosis allowing at the spot therapeutic interventions without wasting precious time.Citation: Lyman R, Yamaguchi Y, Moharir A, Tobias JD. Utility of point-of-care ultrasound in the pediatric intensive care unit. Anaesth pain & intensive care 2019;23(3):314-317

1062. Provider-Based Survey to Determine the Relative Importance of Clinical Factors Used to Make Empiric Antibiotic Decisions

BackgroundDespite advances in rapid organism identification, clinicians must make empiric antibiotic decisions prior to knowing the causative organism. Though many risk factors and patient characteristics have been studied and incorporated into predictive clinical decision support tools for empiric antibiotic prescription, little evidence exists on the relative importance of these factors in clinician judgment. The purpose of this study was to establish how providers evaluate patient and clinical risk factors when making empiric antimicrobial decisions.MethodsAn anonymous survey tool was distributed in February 2019 to medical providers who routinely prescribe antibiotics in 4 acute care hospitals throughout the University of Pennsylvania Health System. Providers were asked to rank the importance of 12 clinical factors using a 5-point scale from not important at all (1) to extremely important (5) in 3 unique clinical scenarios: uncomplicated cystitis, septic shock of unknown etiology, and uncomplicated pneumonia.ResultsResponse rate was 30% (217/732). The importance of each factor varied among different clinical scenarios except for prior antibiotic exposure, local resistance patterns, drug-drug interactions, and treatment guidelines. However, the absolute difference varied by the factor and clinical scenario. Presence of indwelling catheter(s) had the largest absolute variation (median difference of 2 between septic shock and pneumonia, P < 0.001), and it was one of the top 5 most important factors for septic shock, but the least important factor for pneumonia.ConclusionThe importance of clinicians place on clinical factors varies in different clinical scenarios. A better understanding of clinical decision-making in empiric antibiotic prescribing has the potential to guide stewardship efforts and clinical decision support. Disclosures All authors: No reported disclosures.

Learning Abroad: Residents' Narratives of Clinical Experiences From a Global Health Elective.

While resident participation in global health (GH) rotations has grown, little is known about trainee perceptions of the personal value of these international clinical experiences and their importance to the objectives of GH training. We sought to better understand the clinical scenarios experienced during international rotations that residents perceived as most meaningful and the frequency of these experiences across scenarios and participating residents. Using the conceptual framework of Schön's reflection on action, we asked University of Minnesota GH track pediatric and internal medicine-pediatric residents to describe 10 clinical scenarios they found interesting or impactful during their 2016-2017 GH elective. We conducted a qualitative analysis of the deidentified resident narratives and mapped themes to the Accreditation Council for Graduate Medical Education (ACGME) competencies. All eligible residents (n = 13) participated, yielding 129 unique clinical scenarios from 7 countries. We identified 5 thematic groups: (1) addressing challenges in making diagnoses in resource-limited settings; (2) dealing with patient outcomes different from those expected in the United States; (3) encountering and managing diseases in a different clinical context; (4) encountering and managing diseases in a different cultural context; and (5) reflecting on learning and self-growth. Of the 129 unique clinical scenarios, 30% (n = 39) had not been previously experienced by participants. Across the 5 themes, all ACGME core competencies were addressed. Residents identified meaningful scenarios of their GH experiences that are relevant to the educational and clinical objectives of GH training.