ResearchPad - Education https://www.researchpad.co Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Qualities Important in the Selection of Chief Residents]]> https://www.researchpad.co/article/elastic_article_11611 Background

Chief resident selection occurs by numerous methods. Chief residents also fulfill multiple roles, requiring a broad skill set. However, there is little literature on which qualities various stakeholders value in chief resident selection. The objective of this study was to identify the qualities that residents and faculty believe are important for chief residents.

Methods

Following a literature review, educational experts conducted a multi-institutional survey that asked participants to name the qualities they felt were most important in chief residents and to rank-order a predefined list of 10 qualities. Associations were calculated between rank-order and participant age, gender, institutional position, and history of serving as a chief resident.

Results

The response rate for the survey was 43.9% (385/877). Leadership, organization, and communication skills were named by all participants among the most common responses. Residents additionally named approachability, advocacy, and listening skills among their most valued qualities, whereas faculty named strong clinical skills and integrity. Dependability and trustworthiness were the most valued qualities in the rank-order list, whereas strong clinical skills and self-reflection were the least valued. Females valued the ability to manage multiple demands more whereas males valued dependability more. The faculty valued strong clinical skills more than residents.

Conclusion

A variety of qualities are seen as being valuable in chief residents. Additional research is needed to understand what qualities are associated with effective chief resident performance.

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<![CDATA[Exploring the knowledge and attitudes of Cameroonian medical students towards global surgery: A web-based survey]]> https://www.researchpad.co/article/elastic_article_11233 Global surgery is a growing field studying the determinants of safe and affordable surgical care and advocating to gain the global health community's attention. In Cameroon, little is known about the level of knowledge and attitudes of students. Our survey aimed to describe the knowledge and attitudes of Cameroonian medical students towards global surgery.Materials and methodsWe performed an anonymous online survey of final-year Cameroonian medical students. Mann-Whitney U test and Spearman correlation analysis were used for bivariate analysis, and the alpha value was set at 0.05. Odds ratios and their 95% confidence intervals were calculated.Results204 respondents with a mean age of 24.7 years (±2.0) participated in this study. 58.3% were male, 41.6% had previously heard or read about global surgery, 36.3% had taken part in a global surgery study, and 10.8% had attended a global surgery event. Mercy Ships was well known (46.5%), and most students believed that surgical interventions were more costly than medical treatments (75.0%). The mean score of the global surgery evaluation was 47.4% (±29.6%), and being able to recognize more global surgery organizations was correlated with having assumed multiple roles during global surgery studies (p = 0.008) and identifying more global surgery indicators (p = 0.04). Workforce, infrastructure, and funding were highlighted as the top priorities for the development of global surgery in Cameroon.ConclusionMedical students are conscious of the importance of surgical care. They lack the opportunities to nurture their interest and should be taught global surgery concepts and skills. ]]> <![CDATA[Radiation for Glioblastoma in the Era of Coronavirus Disease 2019 (COVID-19): Patient Selection and Hypofractionation to Maximize Benefit and Minimize Risk]]> https://www.researchpad.co/article/elastic_article_11166 We describe the institutional guidelines of a major tertiary cancer center with regard to using hypofractionated radiation regimens to treat glioblastoma as a measure to minimize exposure to coronavirus disease 2019 (COVID-19) while not sacrificing clinical outcomes. Our guidelines review level one evidence of various hypofractionated regimens, and recommend a multidisciplinary approach while balancing the risk of morbidity and mortality among individuals at high risk for severe illness from COVID-19 infection. We also briefly outline strategies our department is taking in mitigating risk among our cancer patients undergoing radiation.

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<![CDATA[The Five Diaphragms in Osteopathic Manipulative Medicine: Myofascial Relationships, Part 2]]> https://www.researchpad.co/article/elastic_article_10524 The article continues the anatomical review of the anterolateral myofascial connections of the five diaphragms in osteopathic manipulative medicine (OMM), with the most up-to-date scientific information. The postero-lateral myofascial relationships have been illustrated previously in the first part. The article emphasizes some key OMM concepts; the attention of the clinician must not stop at the symptom or local pain but, rather, verify where the cause that leads to the symptom arises, thanks to the myofascial systems. Furthermore, it is important to remember that the human body is a unity and we should observe the patient not as a series of disconnected segments but as multiple and different elements that work in unison; a dysfunction of tissue will adversely affect neighboring and distant tissues. The goal of the work is to lay solid foundations for the OMM and the five-diaphragm approach showing the myofascial continuity of the human body.

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<![CDATA[Unilateral Hydrocephalus Due to Lateral Ventricle Colloid Cyst Treated by Neuroendoscopic Approach]]> https://www.researchpad.co/article/elastic_article_10514 Colloid cysts (CCs) are rare brain tumors that cause nonspecific neurological signs associated with acute or chronic increased intracranial pressure. They are usually located in the third ventricle and rarely in the lateral ventricle. This is a report of an unusual case of CC located in the lateral ventricle. A 36-year-old male patient presented a story of progressive holocranial headache that would get worse with head mobilization and cough. Radiological analysis demonstrated enlargement of the right lateral ventricle due to a cyst blocking the right foramen of Monro. The patient underwent endoscopic neurosurgery and the cyst was totally resected. Histological evaluation diagnosed a CC. Postoperative images showed no cyst remaining and normalized ventricular size. The patient evolved with total improvement of the symptoms. Literature review shows that it is a very uncommon entity. Lateral ventricle CCs as a cause for unilateral hydrocephalus is a very rare entity. Neuroendoscopic approach is a first-line treatment option for this condition.

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<![CDATA[The Effect of COVID-19 on Radiation Oncology Professionals and Patients With Cancer: From Trauma to Psychological Growth]]> https://www.researchpad.co/article/elastic_article_10455 <![CDATA[Status and situation of postgraduate medical students in China under the influence of COVID-19]]> https://www.researchpad.co/article/elastic_article_10264 <![CDATA[Readmission Risk Factors and Complications in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis]]> https://www.researchpad.co/article/elastic_article_9460 Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are mucocutaneous hypersensitivity reactions that cause necrosis of the epidermis, often at multiple sites. This process is frequently caused by medications and is associated with significant complications and mortality during hospitalization. However, increasing attention has been drawn to the less studied area of post-hospitalization complications leading to multiple readmissions. We present a patient diagnosed with trimethoprim-sulfamethoxazole induced SJS/TEN, who was readmitted within one week with sepsis. We also discuss the readmission risk factors and post-hospitalization features and complications of SJS/TEN.

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<![CDATA[Independent effects of 15 commonly prescribed drugs on all-cause mortality among US elderly patients with type 2 diabetes mellitus]]> https://www.researchpad.co/article/elastic_article_9089 Most patients with type 2 diabetes mellitus (T2DM) also have hypertension and hyperlipidemia. Consequently, they are taking medications for all three conditions concurrently and the effect of one drug could be confounded with that of another. This study aimed to determine the independent effects of 15 commonly prescribed medications for three conditions on the risk of all-cause mortality among elderly patients with T2DM.Research design and methodsA cohort of 360 437 elderly patients with T2DM from 2007 to 2016 US Medicare data was traced along with cumulative uses of 8 diabetes, 6 hypertension and 1 hyperlipidemia drugs. The relative risk of all-cause mortality for each study drug was estimated using an extended Cox regression analysis adjusting for the concurrent use of other study drugs.ResultsCompared with the no use of each study medication, mortality risk declined with use of 3 diabetes drugs, sodium-glucose cotransporter-2 inhibitors (HR=0.73; 95% CI 0.64 to 0.84), glucagon-like peptide-1 receptor agonists (HR=0.75; 95% CI 0.70 to 0.80) and dipeptidyl peptidase-4 inhibitors (HR=0.94; 95% CI 0.91 to 0.98), the use of 3 blood pressure medications, diuretics (HR=0.89; 95% CI 0.87 to 0.92), angiotensin receptor blockers (HR=0.86; 95% CI 0.84 to 0.89), ACE inhibitors (HR=0.98; 95% CI 0.95 to 1.01) as well as statins (HR=0.83; 95% CI 0.80 to 0.85). It increased moderately with insulin (HR=1.55; 95% CI 1.51 to 1.59), sulfonylureas (HR=1.16; 95% CI 1.13 to 1.20), a small inconsistent amount with metformin (HR=1.05), beta-blockers (HR=1.07), dihydropyridine calcium-channel blockers (HR=0.99) and non-dihydropyridine calcium-channel blockers (HR=1.05). The use of thiazolidinedione had no effect.ConclusionAmong older patients with diabetes, mortality risk decreased importantly with three new diabetes drugs, 3 blood pressure drugs and statins. It increased moderately with sulfonylurea and insulin. Studies of aggressive use of new T2DM drugs instead of sulfonylureas and insulin are needed. Our statin results empirically validate two national guidelines for using statins in older patients with diabetes. However, 23% of study patients never took a statin, suggesting missed opportunities for prevention. ]]> <![CDATA[MON-137 Evaluation of the Timeliness of Serial Denosumab Administrations at the University of Colorado Hospital]]> https://www.researchpad.co/article/elastic_article_8750 BACKGROUND:

Denosumab is an antiresorptive medication commonly used in the treatment of osteoporosis that works by slowing bone loss. This medication should not be delayed or interrupted without initiation of an alternative treatment (i.e. bisphosphonates) as studies have shown that this can lead to rapid bone loss, very high markers of bone turnover, and increased vertebral fracture (VF) risk. It is unknown how frequently dosing is delayed in practice settings and how best practices can ensure timely dosing. Our study aimed to (1) evaluate the frequency and causes of delayed denosumab doses at our institution and (2) compare the incidence of delayed doses before and after implementation of a new electronic ordering process.

METHODS:

We performed a retrospective chart audit for all patients receiving two or more denosumab doses at our institution between 1/1/16-8/11/18 and categorized those whose doses were >/=214 days (7 months) as delayed. We reviewed notes, imaging, and labs in a subset of this population to assess reasons for the delay. On 8/11/18, a new outpatient infusion center (OIC) therapy plan went into place. This plan bundled a one-year denosumab order (2 doses) with an automatic referral to the OIC along with physician reminders for renewal. We compared rates of delayed denosumab dosing before and after implementation of this new order process.

RESULTS:

Between 1/1/16-8/11/18, 385 patients received 1295 doses of denosumab, with 160 (41.6%) receiving 193 instances of delayed doses. We reviewed the charts of 98 individuals who received 111 instances of late doses between 7/6/16-8/11/18. The most prevalent reasons for delays were: delays in follow-up by the patient (27.9%), delays in the provider placing an order for the drug and OIC referral simultaneously (27.9%), and delays in OIC scheduling (18%). During the 14 months after implementation of the new ordering process, 347 patients received 614 instances of denosumab, of which 123 (35.4%) received 128 instances of delayed dosing. This is a relative decrease of 17.5% (p=0.09) for the proportion of patients with a late dose.

CONCLUSIONS AND FUTURE DIRECTIONS:

Nearly half of the patients on denosumab in our hospital received delayed denosumab dosing. Delays were often due to a lack of coordination between subsequent dose order placement and referral to the OIC. Our institution successfully implemented a bundled therapy plan to improve timely dosing. By March 2020, we expect to reassess the post-intervention group to further describe reasons for dosing delays. We also will compare rates of VFs associated with delayed denosumab dosing pre- and post-intervention periods.

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<![CDATA[Towards universal coverage for nutrition services in children under five years—A descriptive analysis of the capacity of level one hospitals to provide nutrition services in five provinces of Zambia]]> https://www.researchpad.co/article/elastic_article_7846 Malnutrition continues to be a major public health challenge in Zambia. To effectively address this, health systems must be well strengthened to deliver an effective continuum of care. This paper examines health systems issues and services in relation to nutritional support to children under five years, in order to identify gaps and propose interventions towards universal coverage of essential nutrition services.MethodsThis analysis utilized data from a cross sectional mixed-methods study on factors associated with Severe Acute Malnutrition (SAM) in under-five children to assess health facility nutrition services on offer at select level-one hospitals in five out of ten provinces in Zambia. Stata version 13 was used for analysis. We conducted univariate analysis to assess nutrition services offered, functionality of equipment and tools, availability of human resource and human resource development, and availability of drugs used for assessment and management of nutrition-related health outcomes.ResultsWe found large variations in the level of nutrition services on offer across districts and provinces. Eighty-eight percent of all the hospitals sampled provided group nutrition counseling and 92% of the hospitals in our sample offered individual nutrition counseling to their clients. Overall, the existence of referral and counter-referral systems between the Community Based Volunteers and hospitals were the lowest among all services assessed at 48% and 58% respectively. We also found inadequate numbers of human resource across all cadres with an exception of nutritionists as recommended by the Ministry of Health.ConclusionsThis study has revealed a number of gaps in the health system and health service delivery that requires to be addressed; most notably, a lack of tools, policies and guidelines, drugs and health specialists to help care for malnourished infants and children. Our findings also reveal inadequate referral systems between the community and health facilities in the management of severe acute malnutrition. Achieving universal coverage for nutrition services in Zambia will require a lot more attention to the health systems issues found in this study. ]]> <![CDATA[Managing possible serious bacterial infection of young infants where referral is not possible: Lessons from the early implementation experience in Kushtia District learning laboratory, Bangladesh]]> https://www.researchpad.co/article/elastic_article_7649 Serious infections account for 25% of global newborn deaths annually, most in low-resource settings where hospital-based treatment is not accessible or feasible. In Bangladesh, one-third of neonatal deaths are attributable to serious infection; in 2014, the government adopted new policy for outpatient management of danger signs indicating possible serious bacterial infections (PSBI) when referral was not possible. We conducted implementation research to understand what it takes for a district health team to implement quality outpatient PSBI management per national guidelines.MethodsPSBI management was introduced as part of the Comprehensive Newborn Care Package in 2015. The study piloted this package through government health systems with limited partner support to inform scale-up efforts. Data collection included facility register reviews for cases seen at primary level facilities; facility readiness and provider knowledge and skills assessments; household surveys capturing caregiver knowledge of newborn danger signs and care-seeking for newborn illness; and follow-up case tracking, capturing treatment adherence and outcomes. Analysis consisted of descriptive statistics.ResultsOver the 15-month implementation period, 1432 young infants received care, of which 649 (45%) were classified as PSBI. Estimated coverage of care-seeking increased from 22% to 42% during the implementation period. Although facility readiness and providers’ skills increased, providers’ adherence to guidelines was not optimal. Among locally managed PSBI cases, 75% completed the oral antibiotic course and 15% received the fourth day follow-up. Care-seeking remained high among private providers (95%), predominantly village health doctors (over 80%).ConclusionsFacility readiness, including health care provider knowledge and skills were strengthened; future efforts should focus on improving provider adherence to guidelines. Social and behavior change strategies targeting families and communities should explore shifting care-seeking from private, possibly less-qualified providers. Strategies to improve private sector management of PSBI cases and improved linkages between private and public sector providers could be explored. ]]> <![CDATA[Incidence and determinants of Implanon discontinuation: Findings from a prospective cohort study in three health zones in Kinshasa, DRC]]> https://www.researchpad.co/article/elastic_article_7634 Kinshasa is Africa's third largest city and one of the continent’s most rapidly growing urban areas. PMA2020 data showed that Kinshasa has a modern contraceptive prevalence of 26.5% among married women in 2018. In Kinshasa’s method mix, the contraceptive implant recently became the dominant method among contraceptive users married and in union. This study provides insight into patterns of implant use in a high-fertility setting by evaluating the 24-month continuation rate for Implanon NXT and identifying the characteristics associated with discontinuation.MethodologyThis community-based, prospective cohort study followed 531 Implanon users aged 18–49 years at 6, 12 and 24 months. The following information was collected: socio-demographic characteristics, Method Information Index (MII) and contraceptive history. The main outcome variable for this study was implant discontinuation. The incidence rate of discontinuation is presented as events per 1000 person/months (p-m), from the date of enrolment. The Cox proportional hazards modelling was used to measure predictors of discontinuation.ResultsA total of 9158.13 p-m were available for analysis, with an overall incidence rate of 9.06 (95% CI: 9.04–9.08) removals per 1000 p-m. Of nine possible co-variates tested, the likelihood of discontinuation was higher among women who lived in military camps, had less than three children, never used injectables or implants in the past, had experienced heavy/prolonged bleeding, and whose MII score was less than 3.ConclusionIn addition to four client characteristics that predicted discontinuation, we identified one programmatic factor: quality of counseling as measured by the Method Information Index. Community providers in similar contexts should pay more attention to clients having less than three children, new adopters, and to clients living military camps as underserved population, where clients have less access to health facilities. More targeted counselling and follow-up is needed, especially on bleeding patterns. ]]> <![CDATA[High or low glycemic index (GI) meals at dinner results in greater postprandial glycemia compared with breakfast: a randomized controlled trial]]> https://www.researchpad.co/article/elastic_article_7270 While circadian control of glucose metabolism is well known, how glycemic index (GI) of carbohydrate-rich meals interacts with time of consumption (breakfast or dinner) to influence postprandial (PP) glucose homeostasis is less well established. The objective of the study was to assess markers of PP glucose homeostasis following high or low GI test meals (TM) consumed either at breakfast or at dinner and following consumption of the subsequent standardized meals (SSM).Research design and methodsRandomized crossover trial in 34 healthy, Chinese, elderly volunteers (mean±SEM age, 56.8±0.83 years), who completed 4 separate study sessions per-protocol, consisting of a high-GI breakfast, low-GI breakfast, high-GI dinner and low-GI dinner TM, followed by a SSM at the subsequent eating occasion. Blood samples were taken for 3 hours after each TM and SSM for glucose, insulin, glucagon, free fatty acids (FFA) and triglycerides (TG) measurements.ResultsConsuming TM at dinner produced greater PP glycemia than breakfast both after TM and SSM (both p<0.0001), irrespective of GI. High-GI TM also produced greater PP glycemia than low-GI TM, both after TM and SSM (both p<0.01), irrespective of time of consumption. No interaction between GI and time were found on PP glycemia, indicating parallel, but independent effects. Combined total areas under the curve of TM+SSM for PP glucose (p<0.0001), PP TG (p<0.0001) and PP FFA (p<0.0001) were all greater when TM taken during dinner compared with breakfast.ConclusionsCarbohydrate-rich meals consumed at dinner leads to significantly worse PP glucose homeostasis than when consumed at breakfast, on top of the independent GI effect of the meal. This may have implications to future type 2 diabetes risk. Moreover, future studies investigating GI/glycemic load (GL) and disease risk associations should factor in timing of GL consumption as an additional variable.Trial registration numberNCT02927600. ]]> <![CDATA[MON-130 Improving the Accuracy and Reliability of Free Thyroxine (FT4) Measurements Through the CDC Clinical Standardization Programs (CSP)]]> https://www.researchpad.co/article/elastic_article_7148 Reliable free thyroxine (FT4) measurements are essential for assessing thyroid function and for correctly diagnosing and treating thyroid disorders. Thyroid hormones play an important role in normal brain development of the fetus, and abnormal FT4 during pregnancy is associated with adverse pregnancy outcomes. Standardization of FT4 measurements, is critical to improving the accuracy and reliability of current methods and thus to improve diagnosis, treatment and prevention of thyroidal illnesses. Currently, there are no serum-based reference materials available for FT4 to assess the accuracy and reliability of FT4 assays. CDC CSP is collaborating with the International Federation of Clinical Chemistry and Laboratory Medicine, and the Partnership for the Accurate Testing for Hormones to address these issues through development of an accurate and sensitive higher-order Reference Measurement Procedure (RMP) for FT4 that will be used to assign target value to serum-based materials. The CDC CSP FT4 reference method is using equilibrium dialysis in combination with liquid chromatography tandem mass spectrometry (LC-MS/MS). FT4 in serum is isolated from the binding proteins in 1 mL equilibrium dialysis cells for 4 hours at 37oC. FT4 is further isolated by extractions prior to LC-MS/MS analysis. To determine the concentration of FT4 in serum, certified primary reference materials are used to prepare calibration materials. Chromatographic separation is achieved using a C18 reverse phase column with a gradient of methanol and water with 0.1% formic acid. Quantification by selective reaction monitoring is performed in the positive mode using electrospray ionization. Two transitions are monitored for each analyte and internal standard, and triplicate injections are used to minimize instrument instability. The within- and between-day imprecision for the CDC RMP are 2.2–3.9% and 1.8–2.6%, respectively. By comparisons with the RMPs at Ghent University in Belgium, Radboud University Medical Center in the Netherlands, and the Reference Material Institute for Clinical Chemistry Standards in Japan, the CDC RMP reported a bias within +2.5% of the mean for all labs. Factors affecting measurement accuracy were investigated, to maximize recovery for optimum performance of the method. FT4 was detectable in all samples, and thus, suitable for analysis of hypo-, eu-, and hyperthyroid patients. A comparison among hypo-, eu-, and hyperthyroid patients of a commercially available immunoassay and the CDC RMP indicated a mean bias of -37.7%. The CDC CSP has also evaluated the RMP for accurate measurement of FT4 in pregnant individuals. This candidate reference method for FT4 in serum demonstrates good accuracy and precision, and can be used as a viable base for accuracy to which routine methods for FT4 can be compared. 1. Van Houcke, S.K., et. al. Clin. Chem. Lab. Med. 2011, 49, 1275–1281.

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<![CDATA[MON-131 Mortality and Glycemic Control Among Patients with Leukemia and Diabetes Mellitus: A Case-Control Study]]> https://www.researchpad.co/article/elastic_article_7062 Background: Unlike with solid organ cancers, little data is available on how diabetes mellitus (DM) and hematologic malignancies interact to affect survival and glycemic control. We examined the impact of DM on survival in patients with leukemia and the effect of leukemia on glycemic control. Materials and Methods: Patients with leukemia with and without DM were matched 1:1 (2007–2017), 70 matched pairs (total N=140 pts) were included in the analysis. We compared characteristics between cases and controls and assessed survival with the Kaplan-Meier method and Cox proportional hazards model. Mixed models compared hemoglobin A1c (HbA1c) and glucose levels over time. Results: The median age of patients at diagnosis was 56 (18–94); 60% were male and 89% had acute leukemia. Among those with DM, HbA1c was only recorded in 25 of 70 patients during the year following cancer diagnosis and was 6.8%. There was no change in HbA1c values over time in these DM patients. Mean glucose was significantly different between DM and non-DM patients (p<0.001). Time (days since leukemia diagnosis) was significant (p<0.001) and there was a significant interaction effect (p=0.01). Glucose values increased in the DM patients during the year following diagnosis, while remaining stable in those without DM. Median follow-up time was 23.2 months. Three-year survival was estimated at 46% for DM patients versus 45% in non-DM pts by Kaplan Meier method (p=0.79). Hazard ratio (stratification for matched pairs) was 1.05 (95% CI: 0.57 - 1.94; p=0.88). Three-year relapse-free survival was estimated at 34% for DM patients versus 43% for non-DM patients (p=0.58). Hazard ratio (stratification for matched pairs) = 1.10 (95% CI: 0.61–1.98; p=0.76). Conclusions: DM did not adversely impact survival in patients with leukemia. Leukemia and its treatment did not affect glycemic control. This should be reassuring to hematologists and endocrinologists who treat patients with leukemia and diabetes.

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<![CDATA[MON-117 Reducing Unnecessary Repeat Vitamin D Testing at a Large Ambulatory Hospital: A Quality Improvement Initiative]]> https://www.researchpad.co/article/elastic_article_7021 Background:

With the increasing interest in the importance and potential benefits of vitamin D, there has been a significant rise in unnecessary vitamin D testing.

The aim of the project was to reduce unnecessary repeat vitamin D testing at Women’s College Hospital by 50% by May 30th 2020.

Methods:

The Model for Improvement framework was used in the design of the quality improvement project to reduce unnecessary repeat vitamin D testing. Problem characterization was conducted to design the intervention to address root causes and iterative Plan-do-Study-Act cycles were used to develop an intervention that incorporated a best practice advisory (BPA). The primary outcome measure was unnecessary vitamin D testing. Unnecessary repeat testing was defined as: repeat 25-hydroxyvitamin D testing within 3 months or repeat 25-hydroxyvitamin D testing after a normal result (>75 mmol/L) in the preceding 12 months.

Secondary outcomes which included BPAs generated, as well as the number of BPAs that resulted in no test being ordered were tracked. Paper-based orders were also tracked as a balancing measure.

Results:

It was identified that 12.7% of vitamin D testing (n= 289/2276) between July 2017 and July 2018 was related to unnecessary repeat testing. Following our cause and effect analysis and problem characterization, it was noted that providers ordered repeat vitamin D testing due to being unaware of prior normal results, as well as due to a knowledge gap of current testing recommendations. If the 25-hydroxyvitamin D order was identified as unnecessary at the time of order entry, a BPA was generated at the point of care. The BPA was implemented on February 4th, 2019. As of August 31st, 2019 based on the analysis of the number of BPAs generated and the number of tests not ordered as a result, there has been a 26% reduction in the number of inappropriate repeat vitamin D orders.

Conclusions:

Based on the preliminary data, a best practice advisory alert for vitamin D testing can be an appropriate QI intervention to reduce unnecessary vitamin D testing. Ongoing data analysis will be conducted to assess the long-term impact and sustainability of this intervention. Next steps include consideration of implementation of force function to reduce inappropriate repeat vitamin D testing.

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<![CDATA[MON-116 Metabolic Parameters in Cancer Patients with and Without Diabetes Mellitus]]> https://www.researchpad.co/article/elastic_article_6981 Background: We have previously examined the link between diabetes mellitus (DM) and malignancy with respect to mortality, but little is known about how the cancer affects glycemic control. Therefore, the aim of this study was to evaluate metabolic parameters in patients with cancer with and without DM. Methods: We selected 1404 patients with newly diagnosed prostate, breast, lung, colorectal, and pancreatic cancer from the institutional cancer registry from 2010–2015. Records were selected and matched 2:1 cancer without DM (n=936) and cancer and concurrent DM patients (n=468). Patients were matched by year of diagnosis, age, gender, and cancer type. Metabolic parameters during the year after cancer diagnosis were examined using linear mixed models with fixed effects for time, cancer type, DM status and individual-specific random effect allowing each patient to have a different intercept. Results: Prostate cancer accounted for the majority of cases (n=199), followed by lung cancer (n=91), breast cancer (n=71), colorectal cancer (n=54), and pancreas cancer (n=53). Mean overall hemoglobin A1c (HbA1c) was 6.9 (1.2)%. Pancreas cancer patients had higher HbA1c overall (p=0.02). There was no change in HbA1c one year post cancer diagnosis (p=0.28). Mean glucose in non-DM was 108(18) mg/dL and 146 (45) mg/dL in DM pts. Lung and pancreas cancer patients had higher glucose values overall (p<0.001). Time (p<0.001), DM (p<0.001) and time * DM (p=0.02) were significant in a mixed model. A decrease in glucose over the year was observed in DM patients across all cancer types. Conclusions: A diagnosis of malignancy does not worsen glycemic control within the first year of cancer diagnosis. This should be reassuring to endocrinologists and oncologists who treat patients with DM and cancer. Longer term studies, and analysis in larger and more diverse patients groups are needed.

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<![CDATA[MON-136 Reducing Unnecessary Inpatient Adrenocorticotropin Stimulation Tests]]> https://www.researchpad.co/article/elastic_article_6922 Background:

Outpatient adrenocorticotropin (ACTH) stimulation tests can be challenging to interpret due to heterogeneously reported cut-offs. Inpatient stimulation tests present additional challenges due to the presence of acute illness and unreliable coordination of dynamic function testing on a busy inpatient service. This study aims to characterize the use of ACTH stimulation tests in hospitalized patients to determine necessity of testing.

Methods:

We conducted an inpatient audit of ACTH simulation tests done to rule out adrenal insufficiency between April 2018 to March 2019 at our institution. Normal post-ACTH response was defined as peak cortisol ≥500 nmol/L. Testing was considered inappropriate in patients with normal post-ACTH response who had a serum cortisol ≥250 nmol/L drawn during the same admission prior to stimulation testing. Cut-offs were based on previous analysis of 195 outpatient stimulation tests.

Results:

During the one-year study period there were 40 inpatients who had an ACTH stimulation test. Nineteen (48%) were considered unnecessary because patients either had a pre-ACTH serum cortisol ≥250 nmol/L and/or a 0-minute cortisol value just prior to the ACTH stimulation test ≥250 nmol/L. Except for a single instance where the patient was inappropriately on prednisone when basal cortisol was tested, all patients with any pre-ACTH cortisol ≥250 nmol/L had a normal post-ACTH response

Conclusion:

Institutions may avoid unnecessary inpatient ACTH stimulation tests by implementing protocols which ensure that basal cortisol levels are drawn and below locally determined cut-offs before proceeding to dynamic testing. To characterize further, a three-year analysis of inpatient ACTH stimulation tests is underway.

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<![CDATA[MON-114 Patient Perceptions of Obesity: African American vs. Caucasian Adults in an Urban Endocrinology Clinic]]> https://www.researchpad.co/article/elastic_article_6803 Introduction: The prevalence of obesity in the U.S. is highest in non-Hispanic black adults (38.4%) and Hispanic adults (32.6%) compared to non-Hispanic white adults (28.6%). Despite known racial disparities in obesity, not much is known about why these differences exist.

Objective: This study evaluated awareness of obesity, perceptions of obesity management, and barriers to adequate care in African American and Caucasian patients.

Methods: A 48-question survey was administered in 2018–2019 to an urban Endocrinology clinic’s adult patients with a body-mass index (BMI) ≥ 30 kg/m2. Chi-squared or Fisher’s exact tests were used to compare variables between groups.

Results: Of 137 respondents, 98 were African American and 39 were Caucasian. Most respondents were female (59–63.9%), had some college education (61.2–71.8%), and an annual income ≤ $50,000 (51.3–63.2%). Comorbidities included hypertension (64–66%), diabetes (73–79%), and arthritis (47–51%). Significantly more Caucasians than African Americans were aware of their BMI (65.8% vs 40%, p=0.0071). Both African Americans and Caucasians perceived their weight to be less than their actual BMI (African Americans: 23.2% perceived “obese” vs. 72.5% BMI 30–39.9 kg/m2 [p<0.001] and 6.3% perceived “extremely obese” vs. 27.6% BMI > 40 kg/m2 [p<0.001]; Caucasians: 37.8% perceived “obese” vs. 66.6% BMI 30–39.9 kg/m2 [p=0.02] and 8.1% perceived “extremely obese” vs. 33.3% BMI > 40 kg/m2 [p=0.01]). Over 90% in both groups agreed that obesity is related to hypertension, diabetes, heart disease, and early death, and 100% considered obesity treatable. Most (72.2–73.7%) recalled their health care provider (HCP) discussing obesity in the past year. Weight loss options discussed were similar between groups. Most discussed diet (70–82%) and exercise (59–62.2%) with HCPs, but few discussed formal weight loss programs (16.3–20.5%), anti-obesity medications (10%), or bariatric surgery (7–10.3%). Barriers were similar for both groups. Top barriers to diet were cost and lack of time and knowledge. Barriers to exercise were lack of time and inability to exercise. Top reasons for not discussing anti-obesity medications and bariatric surgery included concern for side effects or complications, lack of knowledge of the medications/procedures, and cost with surgery.

Conclusions: This study found similar perceptions of obesity management among African American and Caucasian patients with obesity. Despite excellent awareness of obesity as a health problem, decreased awareness of BMI and misperception of weight status were present in both groups. Discussion of diet and exercise was frequent, but discussion of formal weight loss programs, anti-obesity medications, and bariatric surgery was poor. These findings suggest a need for greater patient education and discussion of BMI and treatment beyond diet and exercise for patients with obesity.

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