Visit Diagnosis Research Articles

The Management Pathway of Patients with Cystic Echinococcosis in Iran Prior to Definitive Surgical Treatment.

Patients with cystic echinococcosis (CE) regularly undergo surgery in medical centers in endemic countries. Our understanding of the challenges patients face on the pathway toward the final diagnosis and treatment of CE is poor. The present study was conducted to evaluate the medical care-seeking pathway and the underlying causes of the delayed surgical treatment of CE. Information related to 68 CE patients who underwent surgery in Kerman, Southeast Iran, was collected through face-to-face visits or telephone calls. All the patients were interviewed, and the medical records of each patient were reviewed. The pathway taken by the patient to seek care, the workups performed for diagnosis and management, and the length of time between the onset of symptoms and definitive diagnosis and surgery were evaluated. The patients were visited by at least two physicians; the median number of physicians was four. A total of 47% of the patients were referred to a general practitioner on their first visit. The mean times between the first visit and CE diagnosis and surgery were 1.5 and 3.2 months, respectively. A definitive diagnosis of CE was made for 35.3% of the patients in less than 1 month after the first visit. However, it took 4 months or more for 51.4% of the patients to receive hydatid surgery. The fear of anesthesia and surgery, the cost of management, unsuccessful chemotherapy for CE patients, pregnancy, and issues related to immigrant patients and refugees are among the factors involved in the protraction of CE diagnosis and treatment. Establishing practice guidelines for CE diagnosis and treatment, continuing education for healthcare professionals, and improving access to diagnostic facilities for endemic communities are required to address challenges in the management of CE in endemic regions.

P-1651. Utilizing Electronic Medical Record (EMR) Based Tools to Shorten Duration of Therapy for Community Acquired Pneumonia in the Ambulatory Setting

Abstract Background Community acquired pneumonia (CAP) is a commonly encountered diagnosis is the pediatric outpatient setting. Short durations of antimicrobial therapy of 5-7 days are considered adequate for uncomplicated CAP. We wanted to utilize Electronic medical record (EMR) based tools to standardize treatment durations for CAP. Akron children’s hospital is a large pediatric health care provider in Northeast Ohio and offers pediatric care through more than 30 pediatric offices in the community. This extensive network of primary care offices affords unique opportunities to use the EMR based tools for care standardization. Counts of antibiotic orders based on duration. Methods The antimicrobial stewardship committee developed a guideline for diagnosing and managing community acquired pneumonia and distributed it to all primary care providers. A standardized smart set provided clinical decision support regarding choice of antibiotics and duration of therapy. A visit diagnosis of Community acquired pneumonia prompted the use of the smart set. Smart set usage and duration of therapy (7 days or less vs 8 days or more) were monitored. Baseline data for one year prior and 3 years post-introduction were tracked to measure impact and monitor sustainability of change. Percentage of antibiotic orders based on duration. Results The smart set went live in January 2020. Data review from January 2019 to December 2023 showed the percentage of orders with antibiotic prescriptions of 8 days or more decreased from 97% to 34% while 7 days or less increased from 3% to 66% (Figures 1,2). This change is associated with a high utilization of the pneumonia smart set of > 70 percent (Figure 3). Even though the project is in its maintenance phase the gains have sustained over time. Smart set usage for antibiotic orders Conclusion Utilizing EMR based tools can help shorten antibiotic duration for community acquired pneumonia in a sustainable fashion. This approach holds promise as it can be easily utilized to standardize care for other common outpatient conditions. Expectedly the strategy would be most applicable to health care networks with a wide outreach. It also requires intensive education of providers at the outset, but this can be accomplished by using interested primary care providers to partner with antimicrobial stewardship teams. Disclosures All Authors: No reported disclosures

Orthopedic Patients Are Highly Amenable to Cannabis-Based Products for the Treatment of Musculoskeletal Pain.

Tetrahydrocannabinol (THC)-based and cannabidiol (CBD)-based products are increasing in popularity for the management of pain. Cannabis-based products may serve as a valuable alternative to traditional analgesics such as opioids for pain management among orthopedic patients. The purpose of this study was to investigate the perspective of orthopedic sports medicine patients regarding the use of THC- and CBD-based products for the management of musculoskeletal pain. A short, 11-question survey was distributed to orthopedic sports medicine patients in clinic and via email. Survey participation was voluntary. Retrospective chart review was conducted for participating patients to collect additional data such as visit diagnosis. A total of 182 patients completed the survey. Most were familiar or somewhat familiar with THC (61%) and CBD (63.2%) products and their use for musculoskeletal pain. Of the patients, 53.3% were aware of friends and family currently using CBD products to help manage musculoskeletal pain. Of the patients, 81.3% were amenable to receiving THC-based products and 90.1% were amenable to receiving CBD-based products for the management of their musculoskeletal pain. The patients were statistically more amenable to receiving CBD-based products than THC-based products (P=.017). Among the patients, 85.3% believed cannabis-based products would help in the fight against the opioid epidemic. Orthopedic patients are aware of THC- and CBD-based products, and the majority are willing to receive these products to help manage their musculoskeletal pain and orthopedic-related issues. Orthopedic surgeons should be aware of the increasing popularity of CBD-based products and educate themselves and their patients regarding the appropriate use of them. [Orthopedics. 202x;4x(x):xx-xx.].

Antepartum multidisciplinary approach improves postpartum pain scores in patients with opioid use disorder.

Pregnancies affected by opioid use disorder (OUD) face difficulties with postpartum pain control. This study aims to determine if prenatal anesthesia consultation for patients on medication for opioid use disorder (MOUD) affects maternal postpartum pain control. This is a retrospective cohort study of pregnant patients diagnosed on MOUD who received prenatal care and delivered at a single academic institution between January 2017 and July 2023. Subjects were divided into those who received prenatal anesthesia consultation and those who did not. Severe pain (numerical rating scale 0-10) was defined as score≥7. Statistical analysis was performed using Chi-square, Mann-Whitney U, and multivariable logistical regression tests with significance defined as p<0.05. The cohort included 359 women on MOUD. Of these, 17.8 % (n=64) received anesthesia consultation and 82.2 % (n=295) did not. Factors found associated with receiving anesthesia consultation were prenatal care with an obstetric provider trained in maternal OUD (p<0.01), psychiatric diagnosis (p<0.01) and higher number of prenatal care visits (10.12 vs. 8.99, p=0.007). When comparing pain scores in the first 24 h postpartum, patients with prenatal anesthesia consultation had statistically significant lower rates of severe pain compared to those who did not (25 vs. 44.7 %, p=0.004). Anesthesia consultation (OR 0.34) and cesarean section (OR 2.81) were independent predictors of severe postpartum pain in the first 24 h after delivery. Patients on MOUD who received antenatal anesthesia consultation report lower postpartum pain scores than those without consultation, which supports that multidisciplinary care for pregnant patients with OUD may help the postpartum experience.

HEALTH SYSTEM ADOPTION OF COMMUNITY-BASED EXERCISE FOR OLDER ADULTS TO ADDRESS LONELINESS AND SOCIAL ISOLATION

Abstract Transitioning the delivery of evidence-based programs (EBPs) for older adults from research to community-based settings potentially alters programs’ reach. We compared the demographics of our research participants to our referred community participants after the program’s adoption by Cedars-Sinai, Community Health Improvement (CHI). Research participants enrolled in Falls Prevention EBPs reported decreased levels of loneliness and social isolation and were referred by physicians, social workers, and pharmacists using an order in the electronic medical record (EMR). Clinicians referred 1355 in-person participants (July 2017-March 2020) and 283 virtual (April 2020- May 2021). Enrolled research participants (in-person (n=382) /virtual (n=214)) had an average age of 76.6 / 76.5 years; were 83.4% / 82.5 % female; and non-Hispanic white 42 % / 70.4%; and non-Hispanic Black 43.5% / 8.2%. CHI retained the relationship with the non-profit partner who ran the study’s EBPs and the EMR order remained active and received 391 referrals (July 2021 – March 2024). Referred patients had an average age of 79.5 years, 79.3% female, 59.5% non-Hispanic white, 21.5% Black, 8.2% Hispanic, 5.9% Asian, 3.1% Other; 68.5% had Medicare and 31.7% Medicare Advantage. Referral orders were associated with diagnoses for preventative visits (18.7%), falls (15.6%), and cognitive changes (13.6%). Compared to research participants, community referrals included those with cognitive impairment, were older, more male, and more racially diverse than virtual study participants. Community implementation of EBPs may reach a more diverse population than research participants and successful transition of programs can be facilitated through preserving prior community partnerships and referral pathways.

Development of AI‐4‐AD tools for evaluation and prognosis of AD conversion: multi‐branch network and multi‐task deep learning algorism

AbstractBackgroundAD prevention and early interventions require tools for evaluation of people during aging for diagnosis and prognosis of AD conversion. Since AD is a complicated continuum of neurodegenerative processes, developing of such tools have been difficult because it needs longitudinal and multimodal data which are often complicated and incomplete. To address this challenge, we are developing AI4AD framework using ADNI data.MethodAs shown in Fig. 1, we used the multimodal features of subjects in the initial four time points to predict the disease status after 1.5 years. The informative feature set with available multi‐modal data (MRI, PET and cognitive score (CSs)), is extracted as a multivariate time series. Then, a multi‐scale local temporal attention network (MCLAN) is constructed to extract corresponding deep features from three categories of multivariate time series respectively. Furthermore, a set of statistical features are extracted from multivariate the time series. Subsequently, fusion of selected deep features, statistical features and background knowledge (demographics, CSF, genetics feature) at baseline are performed using a DL feature network. Finally, AD and CSs predictions are realized utilizing multi‐task DL algorism with Adam optimization algorithm and the five‐fold cross‐validation method. 190 CN subjects, 347 MCI subjects and 20 AD subjects were selected according to the first visit diagnosis from TADPOLE database (Table 1a). The longitudinal data for training and ground truth of AD conversion are shown in Table 1(b).ResultThe accuracy (ACC), accuracy (PRE), recall (REC) and F1 score of the proposed AD prediction method in the AD classification were 93.57%, 93.55%, 93.68%, and 93.59%, respectively, which is greatly improved the predictive ability of those by the conventional methods (Table 2). In addition, the root mean square error (RMSE) on the CSs prediction of CDRSB, ADAS11, ADAS13 and MMSE are 0.5863, 0.5238, 0.4747 and 0.5417 respectively.ConclusionOur DL method consolidates multi‐modal medical information at different visits to predict the disease’s progression, which greatly improved AD prognosis from those using traditional DL algorithms (CNN, LeNet and ResNet). The AI4AD framework proposed here can also be tailored to other diseases with similar data characteristics.

Predictors, Diagnoses, and Costs of Emergency Department Visits among Home Care Clients

ObjectivesTo examine factors, diagnoses, and costs associated with emergency department (ED) visits among home care clients. DesignA prospective 1-year follow-up study. Settings and ParticipantsMore information is needed regarding the reasons and costs associated with ED visits by home care clients. Participants were persons aged ≥65 years living in Eastern Finland and receiving regular home care services (n = 293). MethodsData collection included clients’ demographics, health status (Charlson Comorbidity Index), medication use, assessments of physical (Timed Up and Go) and cognitive functioning (Mini-Mental State Examination), Basic and Instrumental Activities of Daily Living, mood (Geriatric Depression Scale, GDS-15) and health-related quality of life [HRQoL, EuroQol (EQ-5D-3 L)]. Logistic regression and univariate analyses of variance were conducted. The costs (total and per person-year) of ED visits were calculated. ResultsThe number of ED visits was 775 during the follow-up (mean 350 days). The likelihood of ED visits was reduced by better HRQoL and increased by a higher GDS-15 score, longer TUG times, and a history of heart failure and decreased glomerular infiltration. The most common primary diagnoses for ED visits were heart failure (8.4%), atrial fibrillation (4.0%), respiratory infection (4.0%), and cystitis (3.5%). The total costs of all ED visits during the follow-up were 251,247 € and internal medicine and surgery accounted for 142,726 € and 89,212 € of the cost, respectively. The costs per person-year were 981 €. Conclusions and ImplicationsHRQoL, depressive symptoms, mobility, and heart and renal failure were associated with the number of ED visits. The most common reasons for ED visits were chronic heart conditions and infectious diseases and the highest costs were incurred by internal medicine treatment. With advanced care planning and active symptom screening and cooperation of home care nurses and physicians, some of the ED visits, for example due to heart failure, might be preventable.

Health-related Internet Use Among New Urology Clinic Patients

ObjectiveTo assess internet usage among new patients seen by urologists and impact on post-consultation understanding for four common conditions: kidney stones, elevated prostate specific antigen, male voiding, and female voiding. MethodsWe performed a prospective study of new urology patients at our diverse urban, academic urology practice for the above conditions over a 1-year period. A voluntary questionnaire assessed patients’ internet use related to referred conditions prior to encounters. Questions evaluated quality of information and patient understanding of symptoms/condition at baseline, after online searches, and after their urology visit. A patient-reported Likert scale of 1 (poor) to 10 (excellent) was used and internet “searchers” were compared to “non-searchers.” Results215 patients participated. Most respondents were Latino (41%) or Black (35%) and English-speaking (81%). Cohorts comprised 130 searchers (60%) and 85 non-searchers (40%). Searchers were significantly younger (median 53 vs. 63 years, P<0.001), more likely to have home internet access (P<0.001), and more general medical internet use (P<0.001). Overall, patients’ understanding of visit diagnoses increased after their encounters (median pre-visit rating 5 vs. post-visit rating 10). Searchers reported a greater post-visit understanding compared to non-searchers (median rating 10 vs. 9, P<0.001), and a greater change in understanding from baseline (median +4 vs. +3, P=0.02). ConclusionInternet use is common amongst younger patients referred to urologists and may be associated with improved understanding of their condition after urologic consultation. Continued investigation of patient uses of and attitude towards popular online resources can help urologists curate resources to benefit patients and providers alike.

Federated learning of medical concepts embedding using BEHRT.

Electronic health record data is often considered sensitive medical information. Therefore, the EHR data from different medical centers often cannot be shared, making it difficult to create prediction models using multicenter EHR data, which is essential for such models' robustness and generalizability. Federated learning (FL) is an algorithmic approach that allows learning a shared model using data in multiple locations without the need to store all data in a single central place. Our study aims to evaluate an FL approach using the BEHRT model for predictive tasks on EHR data, focusing on next visit prediction. We propose an FL approach for learning medical concepts embedding. This pretrained model can be used for fine-tuning for specific downstream tasks. Our approach is based on an embedding model like BEHRT, a deep neural sequence transduction model for EHR. We train using FL, both the masked language modeling (MLM) and the next visit downstream model. We demonstrate our approach on the MIMIC-IV dataset. We compare the performance of a model trained with FL to one trained on centralized data, observing a difference in average precision ranging from 0% to 3% (absolute), depending on the length of the patients' visit history. Moreover, our approach improves average precision by 4%-10% (absolute) compared to local models. In addition, we show the importance of the usage of pretrained MLM for the next visit diagnoses prediction task. We find that our FL approach reaches very close to the performance of a centralized model, and it outperforms local models in terms of average precision. We also show that pretrained MLM improves the model's average precision performance in the next visit diagnoses prediction task, compared to an MLM without pretraining.

Acute Appendicitis After COVID-19 Vaccines in Italy: A Self-Controlled Case Series Study.

Cases of appendicitis were identified in the pivotal randomized clinical trial on BNT162b2 mRNA vaccine and reported from coronavirus disease 2019 (COVID-19) vaccine pharmacovigilance systems. Three cohort studies and two self-controlled case series (SCCS) studies evaluating the association between mRNA vaccines and appendicitis reported discordant results. To address this uncertainty, the present study examines in a large population, with a SCCS design, the association between mRNA (BNT162b2 and mRNA-1273) and, for the first time, viral vector (ChAdOx1-S and Ad26.COV2-S) COVID-19 vaccines and acute appendicitis. The SCCS study design was used to evaluate the association between COVID-19 vaccination and subsequent onset of acute appendicitis. The study was based on record linkage of health archives through TheShinISS application, a statistical tool that locally processes data from regional health care databases according to ad hoc, study-tailored and common data model. The study population included all vaccinated subjects ≥ 12 years old between 27 December 2020 and 30 September 2021. The acute appendicitis was identified through discharge diagnoses of hospital admissions or emergency department visits. Incident cases were defined as those who experienced a first event of acute appendicitis in the study period, excluding subjects with a diagnosis of appendicitis in the previous 5 years. Exposure was defined as the first or second dose of BNT162b2, mRNA-1273 and ChAdOx1-S and the single dose of Ad26.COV2-S. The risk interval was defined as 42 days from the first or second vaccination dose and divided into pre-specified risk subperiods; the reference period was the observation time outside the risk interval. Relative incidences (RI) and 95% confidence intervals (95% CI) were estimated with the SCCS method 'modified for event-dependent exposures', through unbiased estimating equations. The seasonal component was considered as a time-dependent covariate. In the 42-day risk interval 1285 incident cases of acute appendicitis occurred: 727 cases after the first dose and 558 cases after the second dose. In the main analysis, no increased risks of acute appendicitis were observed in subjects vaccinated with BNT162b, mRNA-1273, ChAdOx1-S and Ad26.COV2-S. The subgroup analyses by sex showed an increased risk in the 14-27 day risk interval, in males after the first dose of mRNA-1273 (RI of 1.71; 95% CI 1.08-2.70, p = 0.02) and in females after the single dose of Ad26.COV2-S (RI of 4.40; 95% CI 1.29-15.01, p = 0.02). There was no evidence of association of BNT162b, ChAdOx1-S, mRNA-1273 and Ad26.COV2-S with acute appendicitis in the general population. The results of the subgroup analyses by sex needs to be considered with caution. The multiplicity issue cannot be excluded being these hypotheses two of several hypotheses tested. In addition, relevant literature on the biological mechanism of the disease and evidence of similar effects with other vaccines or with the same vaccines are still lacking to provide strong support for a conclusion that there is an harmful effect in males and females with mRNA-1273 and Ad26.COV2-S.

The Medicare annual wellness visit: An opportunity to improve health system identification of hearing loss?

Hearing loss is prevalent and consequential but under-diagnosed and managed. The Medicare Annual Wellness Visit (AWV) health risk assessment elicits patient-reported hearing concerns but whether such information affects documentation, diagnosis, or referral is unknown. We use 5 years of electronic medical record (EMR) data (2017-2022) for a sample of 13,776 older primary care patients. We identify the first (index) AWV indication of hearing concerns and existing and subsequent hearing loss EMR diagnoses (visit diagnoses or problem list diagnoses) and audiology referrals. For a 20% random sample of AWV notes (n = 474) we compared hearing loss EMR diagnoses to documentation of (1) hearing concerns, (2) hearing loss/aid use, and (3) referrals for hearing care. Of 3845 (27.9%) older adults who identified hearing concerns (mean age 79.1 years, 57% female, 75% white) 24% had an existing hearing diagnosis recorded. Among 474 patients with AWV clinical notes reviewed, 90 (19%) had an existing hearing loss diagnosis. Clinicians were more likely to document hearing concerns or hearing loss/aid use for those with (vs. without) an existing EMR diagnosis (50.6% vs. 35.9%, p = 0.01; 68.9% vs. 37.5%, p < 0.001, respectively). EMR diagnoses of hearing loss were recorded for no more than 40% of those with indicated hearing concerns. Among those without prior diagnosis 38 (9.9%) received a hearing care referral within 1 month. Subgroup analysis suggest greater likelihood of documenting hearing concerns for patients age 80+ (OR:1.51, 95% confidence interval [CI]: 1.03, 2.19) and decreased likelihood of documenting known hearing loss among patients with more chronic conditions (OR: 0.49, 95% CI: 0.27, 0.9), with no differences observed by race. Documentation of hearing loss in EMR and AWV clinical notes is limited among older adults with subjective hearing concerns. Systematic support and incorporation of hearing into EMR and clinical notes may increase hearing loss visibility by care teams.

Improving Pediatric Hypertension Screening in an Academic Primary Care Setting.

Adherence to the American Academy of Pediatrics clinical practice guidelines for screening and managing high blood pressure (BP) is low. This team sought to improve recognition and documentation of relevant diagnoses in patients aged 13-20 years who presented to general pediatric clinics. The primary outcome measure was the proportion of office visits for patients ages 13-20 with a BP ≥ 120/80 with a visit or problem list diagnosis of hypertension or elevated BP. Secondary measures included (1) the proportion of patients who had their BP measured in the right arm, (2) the proportion of patients who had a mid-arm circumference measurement recorded, and (3) the proportion of patients who had a second BP reading measured at the visit. Interventions addressed key drivers for evidence-based high BP screening: standard BP measurement, electronic health record clinical decision support, and clinical pathway adoption. Data were collected over a twenty-seven-month period and plotted using the Laney p' chart. Provider documentation of elevated BP or hypertension improved from a baseline mean of 24% in April 2020 through January 2022 to 41% in February 2021 through June 2022. All secondary outcome measures also demonstrated significant improvement. This project demonstrates the feasibility of improving adherence to best practices of BP measurement in primary care clinics through education, acquisition of resources, and implementation of electronic health record flags for abnormal values.

Travel-associated carbon emissions of patients receiving cancer treatment from an urban safety net hospital.

e13812 Background: Climate change is one of the grand challenges of the 21st century. The U.S. currently emits 11% of the annual global greenhouse gases, and 8-10% of its emissions result from the healthcare industry. Studies on the contribution of patients' commute for cancer treatment to healthcare-associated CO2 emissions remain limited. This study aims to determine the CO2 emissions of patients’ commute for cancer treatment among patients with malignancies at an urban safety net hospital. Methods: We conducted a retrospective study of patients seen at an oncology clinic from July 1, 2022 - June 30, 2023. Demographic data, data on visit diagnosis and indication (e.g., laboratory, infusion, or follow-up visits), and patients' home addresses were collected from the EMR. Distance between patients’ homes and the hospital was calculated using a Google Map API and a macro for distance. Total CO2 emissions from patients’ travel in miles were estimated at 400 grams of CO2 per mile based on the Environmental Protection Agency’s estimate of the average CO2 emissions for a passenger vehicle. The primary outcome was CO2 emissions from patients’ round-trip travel. The total estimated CO2 emissions were converted to equivalents of coal burned, smartphones charged, and gallons of gasoline used based on the EPA equivalencies calculator. Results: Of the 8,235 visits, 5,095 (61.8%) were follow-up/laboratory visits, and 3,137 (38.1%) were chemotherapy infusion visits. Of the 1,080 patients who attended the clinic, the mean age was 63.8 years, 700 (64.8%) were males, 379 (35.1%) were females, 525 (48.6%) were black or African American, 139 (12.9%) were whites. Breast cancer was the most common diagnosis, with 423 (39.2%) of patients. Each patient traveled an average of 9.6 miles round trip (Range = 0.7-298.6 miles) to receive cancer care. An estimated 1,520 grams of CO2 was emitted for each patient’s visit. A total of 79,582 round trip miles was made in 8,235 visits, which corresponds to 31,832 kg of CO2 emissions, equivalent to 35,658 pounds of coal burned, 1,462 propane cylinders used for a home, or 3,872,250 smartphones charged. Conclusions: Cancer care is associated with significant CO2 emissions. Efforts to decrease the overall carbon footprint of cancer treatment through adoption of telemedicine and alternative treatment schedules, are needed to reduce the effect of cancer treatment on the climate. [Table: see text]

Trends over time in liquid biopsy testing in patients with metastatic breast cancer (MBC) across the Mayo Clinic enterprise.

e13036 Background: In January 2023, the FDA approved elacestrant for ESR1-mutated, ER+/HER2- MBC based on a companion diagnostic cell free (cf)DNA test (Guardant Health). In this study, we analyze the trends of liquid biopsy utilization at Mayo Clinic (MC) over a 3 year period to understand the impact of this drug approval on testing patterns and identify emergent alterations in patients (pts) with MBC. Methods: We extracted clinically performed Guardant 360 and Guardant 360 CDx ordered at MC sites in Rochester (MN), Florida (FL), Arizona (AZ), and across 9 additional Mayo Clinic Health System (MCHS) sites. Pts with MBC were identified using the EMR and analyzing visit diagnosis codes and staging information. Shifts in testing patterns were analyzed over a 3 year period from January 1, 2021 - December 31, 2023. Data was collected on the number of tests, serial testing, frequency of pathogenic mutations, and emergent mutations in ESR1 and PIK3CA. Chi-square test was used to compare the categorical values. Results: Between 2021-2023, 2,741 pts with MBC were seen across all sites. A total of 408 cfDNA tests were performed in 370 unique patients with MBC. Most pts (90%) had 1 test performed. The proportion of pts with MBC tested was 85/1350 (6.3%) in 2021, 77/1495 (5.2%) in 2022, and 208/1558 (13.4%) in 2023. The increased proportion of pts tested in 2023 was statistically significant compared to prior years (p&lt;0.0001), while no difference was observed between 2021 and 2022 (p 0.19). Testing patterns varied by site, with FL ordering the highest number of tests, followed by MN and AZ. Of the 34 providers practicing during the entire period seeing more than 10 MBC pts, the number of providers ordering Guardant testing increased from 15/34 (2021) and 14/34 (2022) to 20/34 (2023), though not statistically significant (p 0.15). Of the 41% with EMR-documented staging available, testing was highest in the ER+/HER2- (81.3%) subtype, followed by TNBC (13.6%) and then HER2+ (5.2%). The most commonly identified mutations identified in the first testing were PIK3CA (41.1%), TP53 (40.5%), ESR1 (30.5%), and ATM (13.2%). D538G (8.0%), Y537N (4.4%), and Y537S (3.5%) were frequent emergent mutations seen in ESR1. Conclusions: We observed an increase in cfDNA testing at the start of 2023 which aligns with the FDA approval of elacestrant. We observed variation by site and individual providers that warrants further exploration to improve cfDNA testing in MBC pts at Mayo Clinic.

Stroke Mimics in Children With Moyamoya Arteriopathy

Background Comorbid conditions may result in symptoms that mimic stroke in children with moyamoya arteriopathy. Health care usage for stroke mimics is not well characterized. Methods Consecutive children (aged &lt;18 years) with moyamoya syndrome or disease treated at a single center (2007–2021) were identified from a registry. Data including documentation of headache, anxiety, and functional neurologic disorders were retrospectively abstracted using standardized forms. Encounters were attributed to the comorbid condition when (1) related symptoms led to the visit; (2) the condition was documented as the visit diagnosis; and (3) in the absence of stroke, transient ischemic attack, or seizure. Results We identified 32 children (63% female) with symptomatic moyamoya arteriopathy diagnosed via imaging at a median age of 7.5 years (range, 0.7–17) years, all treated with revascularization surgery. During follow‐up (median, 6.7 years after diagnosis [interquartile range, 4.0–8.3]), 81% of patients reported headache, 53% reported anxiety, 19% reported panic attacks, and 6% developed a functional neurologic disorder. Both patients with functional neurologic disorder also had migraines and anxiety. In 10 patients (31% of the cohort), a stroke mimic led to 33 emergency department encounters and 9 hospital admissions; 9 received head imaging (magnetic resonance imaging, computed tomography, or computed tomographic angiography) as part of the workup. Conclusion Headaches, anxiety, and functional neurologic disorders may mimic stroke symptoms in children with moyamoya arteriopathy, leading to significant health care usage. While providers should remain vigilant for stroke, early recognition of stroke mimics should promote interventions to address comorbid conditions.

Primary Care Enhanced Access Services and the Association With Nonurgent Pediatric Emergency Department Utilization and Child Opportunity Index.

This study aims to examine the association between primary care practice characteristics (enhanced access services) and practice-level rates of nonurgent emergency department (ED) visits using ED and practice-level data. Survey data suggest that enhanced access services within a child's primary care practice may be associated with reduced nonurgent ED visits. We performed a cross-sectional analysis of nonurgent ED visits to a tertiary pediatric hospital in Western Pennsylvania with nearly 85,000 annual ED visits. We obtained patient encounter data of all nonurgent pediatric ED (PED) visits between January 2018 and December 2019. We identified the primary care provider at the time of the study period. For each of the 42 included offices, we determined the number of unique children in the office with a nonurgent PED visit, allowing us to determine the percentage of children in the practice with such a visit during the study period. We then stratified the 42 offices into low, intermediate, and high tertiles of nonurgent PED use. Using Kruskal-Wallis tests, logistic regression, and Pearson χ 2 tests, we compared practice characteristics, enhanced access services, practice location Child Opportunity Index 2.0, and PED visit diagnoses across tertiles. We examined 52,459 nonurgent PED encounters by 33,209 unique patients across 42 outpatient offices. Primary care practices in the lowest ED visit tertile were more likely to have 4 or more evenings with office hours (36% vs 14%, P = 0.04), 4 or more evenings of weekday extended hours (43% vs 14%, P = 0.05), and at least 1 day of any weekend hours (86% vs 29%, P = 0.01), compared with practices in other tertiles. High PED use tertile offices were also associated with lower Child Opportunity Index scores. Primary care offices with higher nonurgent PED utilization had fewer enhanced access services and were located in neighborhood with fewer child-focused resources.

Impact of an Inter-Professional Clinic on Pancreatic Cancer Outcomes: A Retrospective Cohort Study.

Background: Pancreatic ductal adenocarcinoma (PDAC) presents significant challenges in diagnosis, staging, and appropriate treatment. Furthermore, patients with PDAC often experience complex symptomatology and psychosocial implications that require multi-disciplinary and inter-professional supportive care management from health professionals. Despite these hurdles, the implementation of inter-professional clinic approaches showed promise in enhancing clinical outcomes. To assess the effectiveness of such an approach, we examined the impact of the Wallace McCain Centre for Pancreatic Cancer (WMCPC), an inter-professional clinic for patients with PDAC at the Princess Margaret Cancer Centre (PM). Methods: This retrospective cohort study included all patients diagnosed with PDAC who were seen at the PM before (July 2012-June 2014) and after (July 2014-June 2016) the establishment of the WMCPC. Standard therapies such as surgery, chemotherapy, and radiation therapy remained consistent across both time periods. The cohorts were compared in terms of survival rates, disease stage, referral patterns, time to treatment, symptoms, and the proportion of patients assessed and supported by nursing and allied health professionals. Results: A total of 993 patients were included in the review, comprising 482 patients pre-WMCPC and 511 patients post-WMCPC. In the multivariate analysis, adjusting for ECOG (Eastern Cooperative Oncology Group) and stage, it was found that post-WMCPC patients experienced longer median overall survival (mOS, HR 0.84, 95% CI 0.72-0.98, p = 0.023). Furthermore, the time from referral to initial consultation date decreased significantly from 13.4 to 8.8 days in the post-WMCPC cohort (p < 0.001), along with a reduction in the time from the first clinic appointment to biopsy (14 vs. 8 days, p = 0.022). Additionally, patient-reported well-being scores showed improvement in the post-WMCPC cohort (p = 0.02), and these patients were more frequently attended to by nursing and allied health professionals (p < 0.001). Conclusions: The implementation of an inter-professional clinic for patients diagnosed with PDAC led to improvements in overall survival, patient-reported well-being, time to initial assessment visit and pathological diagnosis, and symptom management. These findings advocate for the adoption of an inter-professional clinic model in the treatment of patients with PDAC.

Malignancy Risk Associated With the Use of Systemic Immunomodulatory Therapy in the Management of Noninfectious Uveitis

Patients with noninfectious uveitis (NIU) can require treatment with systemic immunomodulatory therapy (IMT), but it is unclear whether IMT drug categories increase the risk of malignancy in NIU patients. The purpose of this study is to determine if the use of systemic IMT in patients with NIU is associated with an increased risk of malignancy. Clinical cohort study. Patients were identified from a US administrative medical claims database including some Medicare Advantage and commercial plans, from 2000 to 2022. About 318,498 NIU patients were identified. Enrollees were included in the analysis if they met the following criteria: continuous enrollment in the plan for at least 1 year, and at least 2 consecutive visit diagnoses of any type of NIU, after initiation of systemic IMT. We compared the rates of incident malignancy in NIU patients treated with IMT versus the rates among NIU patients not treated with IMT. Multivariable Cox regression models were used to predict the hazard of developing incident cancer. Of the 318,498 patients with NIU identified over a 15-year period, 318,006 did not develop malignancy, and 492 did develop malignancy. Of the patients that developed a malignancy, 280 (57%) were treated with systemic corticosteroids; 204 (41%) were treated with antimetabolites; 44 (9%) were treated with T cell inhibitors; 108 (22%) were treated with TNF alpha inhibitors; 2 (0.004%) were treated with interleukin-6 (IL-6) inhibitors; and 1 was treated with CD-20 antibodies. There were no malignancies reported in the group treated with alkylating agents. There was no association between any of the drug classes and incidence of malignancy. This study suggests that there is no increased risk of malignancy associated with the use of systemic IMT for patients with NIU.

Pediatric Population Management Classification for Children with Medical Complexity.

Improving the overall care of children with medical complexity (CMC) is often beset by challenges in proactively identifying the population most in need of clinical management and quality improvement. The objective of the current study was to create a system to better capture longitudinal risk for sustained and elevated utilization across time using real-time electronic health record (EHR) data. A new Pediatric Population Management Classification (PPMC), drawn from visit diagnoses and continuity problem lists within the EHR of a tristate health system, was compared with an existing complex chronic conditions (CCC) system for agreement (with weighted κ) on identifying CCMC, as well as persistence of elevated charges and utilization from 2016 to 2019. Agreement of assignment PPMC was lower among primary care provider (PCP) populations than among other children traversing the health system for specialty or hospital services only (weighted κ 62% for PCP vs. 82% for non-PCP). The PPMC classification scheme, displaying greater precision in identifying CMC with persistently high utilization and charges for those who receive primary care within a large integrated health network, may offer a more pragmatic approach to selecting children with CMC for longitudinal care management.

Association between days for concussion recovery and initial specialty clinic evaluation within 48 hours

BackgroundResearchers have highlighted the importance of early access to concussion care within one week of injury in reducing recovery times. However, a persisting question for concussion researchers is “just how early is important?” The purpose of this study was to examine differences in recovery time as predicted by the number of days elapsed since injury (DSI) to initial evaluation among patients who had access to a specialty concussion clinic within seven days. We hypothesized that DSI group membership, even within seven days, would significantly predict risk of protracted recovery (i.e., beyond 21 days).MethodsIn this archival study, retrospective data were gathered from electronic medical records between September 2020 to March 2022. Records of participants between ages 12–18, those diagnosed with a sports-related concussion based on initial clinic visit diagnosis by a medical provider and those who established care within seven days of injury at a large pediatric specialty concussion clinic were examined. Participants were divided into three DSI groups (patients seen in < 48 h: “acute”, patients seen between 49 h < and < 96 h: “sub-acute”, and patients seen between 97 < and < 168 h: “post-acute”). A general linear model was constructed to examine relationships between relevant concussion factors (e.g., Post Concussion Scale Score, neurodevelopmental history, psychiatric history, concussion history, migraine history, overall VOMS change score, cognitive testing, sex, age, race, and ethnicity) that were either significant in the preliminary analysis or in clinical judgement and recovery time. Adjusted odds ratios (OR) were derived from a binary logistic regression model, in which recovery time was normal (≤ 21 recovery days) or protracted (> 21 recovery days).ResultsA total of 856 participants were eligible. Adolescents in the acute group (M = 15.12, SD = 8.04) had shorter recovery times in days compared to those in the sub-acute (M = 17.98, SD = 10.18) and post-acute (M = 21.12, SD = 10.12; F = 26.00, p < .001) groups. Further, participants in the acute (OR = 4.16) and sub-acute (OR = 1.37) groups who accessed specialty concussion clinics within 48 h were 4 times more likely to have a normal recovery and recovered approximately 6 days faster than the post-acute care group.ConclusionsEarlier concussion care access predicted recovery times and was associated with lower risk for protracted recovery.