Successful Outpatient Management of Severe Ionized Hypercalcemia Secondary to Cholecalciferol Ingestion in a Puppy

ABSTRACT A 4 mo old female intact boxer was presented because of polyuria, lethargy, and vomiting after ingestion of cholecalciferol rodenticide roughly 3 days prior. Blood work revealed an ionized hypercalcemia 2.23 mmol/L (reference range 1.04–1.33 mmol/L) on presentation. Because of financial limitations, the patient was unable to be hospitalized for standard of care. She was treated with a pamidronate infusion and discharged with medical management to include oral prednisone, furosemide, and subcutaneous fluids. The dog’s signs, body weight, and biochemical parameters were serially monitored over 3 wk as the ionized hypercalcemia resolved. To the authors’ knowledge, this is the first published report documenting a successful outpatient medical protocol for potentially life-threatening hypercalcemia secondary to cholecalciferol toxicosis in a puppy.

Establishing an alternative accommodation for stable hospitalised antepartum patients: barriers and challenges

BackgroundPatients in remote communities who risk premature delivery require transfer to a tertiary care centre for obstetric and neonatal care. Following stabilisation, many patients are candidates for outpatient management but cannot be discharged to their home communities due to lack of neonatal intensive care unit (ICU) support.ProblemWithout outpatient accommodation proximal to neonatal ICU, these patients face prolonged hospitalisation—an expensive option with medical, social and psychological consequences. Therefore, we sought to establish an alternative accommodation for out-of-town stable antepartum patients.MethodsQuality Improvement approaches were used to identify process strengths and opportunities for improvement on the antepartum ward in a tertiary care centre. Physician and patient surveys informed outpatient accommodation programme development by a multidisciplinary team. The intervention was implemented using a plan–do–study–act cycle. Barriers to patient discharge and enrolment in the programme were analysed by completing thematic and strengths–weaknesses–opportunities–threats (SWOT) analysis.ResultsPhysicians broadly supported safe outpatient management, whereas patients were hesitant to leave the hospital even when physicians assured safety. Our alternative accommodation was pre-existing and cost-effective, however, we encountered significant barriers. The physical space limited family visits and social interaction, lacked desired amenities,and the programme proved inconvenient to patients. The thematic and SWOT analysis identified aspects of the intervention which can be optimised to develop future actionable strategies.ConclusionThe utilisation of acute care beds is costly for the healthcare system and must be allocated judiciously. Patient needs, experience and health system barriers need to be considered when establishing alternative outpatient accommodations and strategies for stable antepartum patients.

Fluvoxamine for Outpatient COVID-19 to Prevent Hospitalization: A Systematic Review and Meta-Analysis

Importance: Widely available and affordable options for the outpatient management of COVID-19 are needed, particularly therapies that prevent hospitalization. Objective: Perform a meta-analysis of the available randomized clinical trial evidence for fluvoxamine in the outpatient management of COVID-19. Data Sources: World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov. Study Selection: Completed outpatient trials with available results which compared fluvoxamine to placebo. Data Extraction and Synthesis: We followed the PRISMA 2020 guidelines. We extracted study details in terms of inclusion criteria, trial demographics and the pre-specified outcome of all-cause hospitalization. Risk of bias was assessed by the Cochrane Risk of Bias 2 tool. We conducted a frequentist random effects meta-analysis, as well as two sensitivity analyses using a Bayesian random effects meta-analysis with different estimates of prior probability: a weakly neutral prior (50% chance of efficacy with 95% confidence interval for Risk Ratio [RR] between 0.5 and 2) and a moderately optimistic prior (85% chance of efficacy). We contextualized the results by estimating the probability of any effect (RR ≤1) and moderate effect (RR ≤0.9) on reducing hospitalization. Main Outcome(s) and Measure(s): All cause hospitalization. Results: 2196 participants were included from 3 identified trials. The risk ratios for hospitalization were 0.75 (95%CI, 0.57-0.97) for the frequentist analysis, 0.78 (95%CI 0.58-1.08) for the Bayesian weakly neutral prior, and 0.73 (95%CI, 0.53-1.01) for the Bayesian moderately optimistic prior. Depending on the scenario, the probability of any effect on hospitalization ranged from 94.1% to 98.3% and a moderate effect from 81.6% to 91.1%. Conclusions and Relevance: Under a variety of assumptions, fluvoxamine shows a high probability of preventing hospitalization in outpatients with COVID-19. While ongoing randomized trials are important to evaluate alternative doses, explore the effectiveness in vaccinated patients, and provide further refinement to these estimates, fluvoxamine could be recommended as a treatment option, particularly in resource-limited settings or persons without access to SARS-CoV-2 monoclonal antibody therapy or direct antivirals.

Application of PSO-based LSTM Neural Network for Outpatient Volume Prediction

In order to study the construction method of long- and short-term memory neural network model, which is based on particle swarm optimization algorithm and its application in hospital outpatient management, we have selected historical data of outpatient volume of relevant departments in our hospital. Furthermore, we have designed and developed the outpatient volume prediction model, which is based on long- and short-term memory neural network. Additionally, we have used particle swarm optimization algorithm (PSO) to optimize various parameters of long- and short-term memory network and then utilized this optimized model to accurately predict the outpatient volume. Experimental observations, which are collected through the results of monthly outpatient volume prediction, show that Root Mean Square Error (RMSE) of the particle swarm optimized LTMN model on the test set is reduced by 48.5% compared with the unoptimized model. The particle swarm optimization algorithm has efficiently optimized the prediction model, which makes the model better predict the trend of outpatient volume and thus provide decision support for medical staff's outpatient management.

Outcomes Following Acute Pulmonary Embolism in an Irish Population of over 1 Million Individuals: Opportunities for Quality Improvement and More Effective Resource Utilisation

Introduction Pulmonary embolism (PE) is a leading cause of cardiovascular morbidity worldwide. The risk of early death in the setting of untreated PE may be as high as 30%. However, diagnostic and therapeutic advances in recent years have led to a progressive decline in global PE-related mortality and recent data describing rates of in-hospital death following PE suggest a mortality rate of approximately 5-15%. Moreover, strategies directed at stratification of PE severity have been shown to safely identify a sub-group of low-risk patients (up to 30-50% of all patients) for whom outpatient management is feasible without the need for hospital admission. Avoiding hospitalisation for low-risk PE patients is associated with improved patient satisfaction and avoids exposing patients to the risks associated with hospital admission. Ambulatory PE management would also be predicted to lead to significant healthcare cost-savings. However ambulatory care models for low-risk PE appear to be under-utilised despite these potential benefits. Barriers to implementation include access to outpatient follow-up services and the perceived risks associated with this model of care. The Ireland East Hospital Group (IEHG) is the largest hospital network in the Republic of Ireland, consisting of 11 hospitals (including large academic centres, community general hospitals and the national maternity hospital). The IEHG serves a population of over 1.1 million individuals. We sought to determine the frequency of admissions to hospital with PE and to assess key outcomes, including length-of-stay (LOS) and in-hospital mortality within this population. Methods Data pertaining to PE diagnosis from January 2018 to December 2020 were obtained from NQAIS Clinical (National Quality Assessment and Improvement System; an electronic reporting tool which is populated with anonymised data extracted from the hospital in-patient enquiry system). This system compiles diagnostic data on all patients by ICD-10 code at the time of discharge. For the purposes of this analysis the ICD-10 codes I26.0 and I26.9 were used to identify patients with PE and only admission episodes where PE was the primary diagnosis were included; cases of 'secondary PE' (historical PE or hospital-acquired) were excluded. Projected population figures, extrapolated from Census 2016 data, were obtained from Health Atlas Ireland (an open-source application providing access to datasets developed by the Health Intelligence Unit of the Health Service Executive of Ireland). Results During the 3-year study period, 958 in-patient episodes occurred where PE was recorded as the primary diagnosis, corresponding to an incidence of 0.37 per 1000 adults per annum (95% CI 0.35 to 0.40). The incidence was highest in the over 85 years age-group (1.07 per 1000 per annum; 95% CI 0.80 to 1.33). PE was more common in women in all age-groups apart from the 46-65 years age group [males: 0.51 (95% CI 0.44-0.51) vs females: 0.36 (95% CI 0.3-0.42) per 1000]. In 82.7% of episodes, the ultimate discharge destination was to home. In 5.3% the discharge destination was a nursing home and 4.6% were transferred to another hospital. The all-cause in-hospital mortality rate was 3.1% (30 fatalities; 18 females, 12 males). Most deaths occurred in the 66-85 years age-group (n=14), with 9 fatalities in the age >85 years group and 7 fatal PE events in the 46-65 years age-group. Average hospital LOS was 7.8 days. 8.9% of inpatient episodes resulted in same-day discharge. In 55.9% of episodes, discharge occurred after day 4. Those discharged to home had an average length of stay of 6.31 days, while patients awaiting nursing home facilities averaged 26.5 days. Conclusion The incidence of acute presentation with PE within this population is consistent with international reports. The rate of in-hospital mortality compares favourably with these international standards. The mortality rate may reflect improvements in PE care but may also reflect the inclusion of a significant number of 'low-risk' individuals in the analysis (many of whom may have been suitable for outpatient management). The mortality rate might also reflect increased detection of small, low-risk distal PE (as a result of advances in diagnostics). In any event, these data suggest that more widespread implementation of outpatient PE management is likely to be feasible and would represent an opportunity for improved resource utilisation. Disclosures Ni Ainle: Leo Pharma: Research Funding; Actelion: Research Funding; Daiichi-Sankyo: Research Funding; Bayer Pharma: Research Funding. Kevane: Leo Pharma: Research Funding.

An Outpatient Management for First Cycle of Venetoclax and Hypomethylating Agents Results in Reduced Infection Rate and Hospitalizations in Acute Myeloid Leukemia Patients

Introduction In the setting of clinical trials Venetoclax (VEN) combined with hypomethylating agents (HMAs) has shown fair activity in Relapsed/Refractory (R/R) AML and impressive results in newly diagnosed (ND) elderly AML patients. However, no clear guidelines are available on real-life management, especially in the outpatient setting. This study involving AML patients treated with VEN combined with HMAs aims to amelioratate physicians' knowledge about the administration of these regimens. Methods This is a single-center retrospective study involving AML patients treated with Venetoclax combined with HMAs. Data were collected in accordance with GCP and Helsinky declaration. Adverse events (AEs) were graded according to CTCAE v4.03. Survival is estimated with Kaplan-Meyer method. Results A total of 59 AML patients, 43 R/R and 16 ND, have been treated with VEN plus HMAs from March 2018 to June 2021 and completed at least 1 therapy course (range 1-9, median 2, IQR 1.0 - 4.0). The median age was 70 (range 22-88) years and 15.3 % had a documented ECOG score greater than 1. VEN was combined with azacitidine in 35/59 (59.3 %) patients and with decitabine in 22/59 (37.3 %) patients (Table 1: patient and disease characteristics). The majority of patients (40/59, 67.8 %) (28/43 R/R, 12/16 ND) received the first cycle as out-patients, 19 out of 59 (32.2 %) patients were hospitalized and used as control. No significant differences with regards to disease and patients' characteristics were observed between in- and out-patients. During the ramp-up phase only 2 cases of tumor lysis syndrome (TLS) and 5 AEs were documented. During the first course, a total of 54 AEs were recorded and experienced by 16 over 19 hospitalized patients (84.2 %) and 20 over 40 outpatients (50 %). The 30-day and 60-day mortality were 2.5% (1/40) and 20 % (8/40), respectively, among patients receiving first course as out-patents, comparable to those documented in hospitalized patients. Overall, we reported 118 AEs, of which 74 were grade III-IV and the most common were hematological 23/74 (31.1 %) or infective 41/74 (55.4 %). Regarding infections, at least one bacterial infection was experienced in 10/40 (25%) and 12/19 (63.1%) patients of the outpatient and hospitalized cohorts, respectively (p = 0.009, IC 1.37 - 19.74, OR 4.98). Pneumonia and sepsis (13 and 18 cases) were the most frequent infections. Sepsis incidence was higher among hospitalized patients (13/19, 68.4 %, vs 5/40, 12.5 %, p = 0.000029). No significant difference in infective risk was documented between R/R and ND patients (65.1 vs 50 %). Thirty-two out of 59 (54.2 %) patients experienced at least one VEN withdrawal due to treatment toxicity. Twenty out of 43 AEs requiring VEN suspensions occurred during the first cycle. Patients treated in-patient showed the tendency for a higher probability to suspend therapy due to treatment toxicity (10/19 IN vs 10/40 OUT, p = 0.04). While twenty-three out of 59 (38.9 %) patients were hospitalized for treatment complications at least once, the average number of days spent in hospital was significantly different between patients receiving the first course as outpatients as compared to those who were hospitalized (5.9 vs 39.7, respectively, p < 0.0001). With a median follow-up of 117 days (IQR 92 - 173.75) in ND patients the Overall Response Rate (ORR), defined as CR + CRi + HI, was 62.5 % (10/16), with a CR/CRi rate of 50 % (8/16) and a median OS of 247 days (95% C.I. 177.71- 316.58)(Fig 1a). In the R/R setting the ORR rate was 41.8 % (18/43), with a CR/CRi rate of 25.6 % (11/43) and a median OS of 219 days (95% C.I. 91.8 - 346.2) (Fig 2a). No differences in OS were documented between patients who underwent VEN plus HMAs outpatient and patients who underwent the first cycle hospitalized (p = 0,38) (Fig. 1b-2b). Conclusions With the limitations of a single-center retrospective study, our real-life data indicate that VEN plus HMAs is feasible in an outpatient management, with minimal TLS rate and no limiting toxicities. Of note, infections rate was acceptable, bacterial infections and sepsis risk were lower in outpatients than in hospitalized patients. There was no significant impact of the outpatient management on treatment effectiveness, with data in line with published AML cohorts. Further studies evaluating the clinical, social and economic impact of outpatient VEN-based treatments are highly warranted. Figure 1 Figure 1. Disclosures Papayannidis: Pfizer, Amgen, Novartis: Honoraria. Cavo: Adaptive Biotechnologies: Consultancy, Honoraria; GlaxoSmithKline: Consultancy, Honoraria; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel Accommodations, Speakers Bureau; AbbVie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Sanofi: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: TRAVEL, ACCOMMODATIONS, EXPENSES, Speakers Bureau; Novartis: Honoraria; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Bristol-Myers Squib: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Curti: Jazz Pharma: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; Abbvie: Membership on an entity's Board of Directors or advisory committees.

Evaluation of Real-World Patient Volume for a Low Risk Pulmonary Embolism Outpatient Clinic at a Large, Public Medical Center

Introduction: Guidelines from the American Society of Hematology recommend consideration of outpatient management, rather than hospitalization, for patients with pulmonary thromboembolism (PTE) with low risk of complication. The simplified Pulmonary Embolism Severity Index (sPESI) is frequently used for PTE risk stratification and selection for outpatient management, where an sPESI of 0 is associated with a low risk of recurrent thromboembolism, non-fatal bleeding, and death. Prior to developing an outpatient care pathway for low risk PTE at a large, public academic medical center, we sought to assess the potential clinic volume by determining the number of patients seen at our institution with low risk acute PTE. We also sought to capture other features that may preclude outpatient management including renal impairment, thrombocytopenia, and obesity, which may prevent direct oral anticoagulant (DOAC) use, and lack of insurance, which may impede access to affordable anticoagulation and clinic follow-up. Methods: We retrospectively identified patients with acute PTE by reviewing computed tomography (CT) of the chest with contrast or CT angiography performed during a one-year period (Oct 1, 2018 to Sept 30, 2019) using CPT codes. Imaging reports were manually reviewed to determine if acute PTE was present. sPESI variables were collected: age >80, history of cancer, history of cardiopulmonary disease, heart rate (HR) ≥110bpm, systolic blood pressure (SBP) <100mmHg, and oxygen saturation (O 2) <90%. Medical history variables were identified using ICD-10 codes. Vital sign values were determined by identifying peak or nadir as appropriate within 24 hours of encounter initiation. Additional demographic and clinical variables collected included sex, weight, body mass index (BMI), insurance status, serum creatinine, platelet count, and length of stay for admitted patients. Readmission was determined by reviewing documentation within 30 days of initial encounter. Values were reported using frequencies with percentages and means with standard deviation and/or range. Comparisons were performed using chi squared tests and t tests as appropriate. Results: Of 587 CT chest imaging studies identified, 199 (34%) demonstrated acute PTE (Figure 1). The majority (n=174, 87%) had an sPESI of 1 or greater. Points were more frequently gained due to SBP <100mmHg (n=109, 63%), HR ≥110bpm (n=105, 60%), and O 2 ≤90% (n=90, 52%). History of cancer was present in 54 patients (31%) and history of cardiopulmonary disease in 81 patients (47%), with a total of 113 patients (65%) having a history of either. Only 25 patients (13%) had a low risk sPESI score of 0. Two patients with sPESI of 0 were excluded from further analysis due to age <18 and transfer to an outside hospital. Table 1 includes a comparison of the demographic and clinical features of all patients with acute PTE versus those with sPESI of 0. Of those patients with a low risk sPESI, 3 patients (13%) had another indication for hospital admission aside from acute PTE (Figure 1). Three patients (13%) had a BMI greater than 40kg/m 2 and a weight greater than 120 kilograms. No patients had significant renal impairment, with a serum creatinine ranging between 0.5-1.5mg/dL. No patients had significant thrombocytopenia. Three patients (13%) were uninsured, 1 of whom was admitted for another indication. The majority of patients with sPESI of 0 were admitted (n=19, 83%) with an average length of stay of 1.8 days (SD 1.6, range 0.2-7.4). Two patients were discharged from the emergency department (ED), and 2 patients were diagnosed and managed by an outpatient provider without contact with the ED or hospital. Only 1 patient was readmitted to the hospital within 30 days for reasons unrelated to PTE. Conclusions: Our results indicate that the annual volume for a low risk PTE outpatient management pathway at a large, public medical center would be low, with only 20 patients meeting eligibility per sPESI in 12 months. Patients were frequently disqualified for vital sign abnormalities, but over half were ineligible due to comorbidities. This quantification will allow our institution and others that are similar to gauge the potential resource allotment needed for low risk pathway development. In addition, we demonstrate that 10% of eligible patients were uninsured, emphasizing that access to affordable anticoagulation and follow-up is necessary when developing outpatient PTE care models. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.