Recognising, assessing and managing chest pain

Chest pain is a common medical symptom that paramedics attend to in the out-of-hospital environment. The causes of chest pain and the signs and symptoms are explained in this article, alongside tools that could be useful in diagnosis, such as clinical risk scores and troponin testing. Finally, pain management strategies that use a balanced approach for optimal patient care are referred to, with some specificity for cardiac chest pain explained.

Imaging and Treatment of Posttraumatic Ankle and Hindfoot Osteoarthritis

Posttraumatic osteoarthritis of the ankle and hindfoot is a common and frequently debilitating disorder. 70% to 90% of ankle osteoarthritis is related to prior trauma that encompasses a spectrum of disorders including fractures and ligamentous injuries that either disrupt the articular surface or result in instability of the joint. In addition to clinical evaluation, imaging plays a substantial role in the treatment planning of posttraumatic ankle and hindfoot osteoarthritis. Imaging evaluation must be tailored to specific clinical scenarios and includes weight bearing radiography that utilizes standard and specialty views, computed tomography which can be performed with a standard or a weight bearing technique, magnetic resonance imaging, and ultrasound evaluation. This review article aims to familiarize the reader with treatment rationale, to provide a brief review of surgical techniques and to illustrate expected imaging appearances of common operative procedures performed in the setting of posttraumatic ankle and hindfoot osteoarthritis, such as joint-preserving procedures, ankle fusion, subtalar fusion, tibiotalarcalcaneal fusion and ankle arthroplasty. Preoperative findings will be discussed along with the expected postoperative appearance of various procedures in order to improve detection of their complications on imaging and to provide optimal patient care.

515. Evolution of Treatment Patterns for Patients Hospitalized with COVID-19 in the United States

Background COVID-19 remains a threat to public health, with over 30 million cases in the US alone. As understanding of optimal patient care has improved, treatment guidelines have continued to evolve. This study characterized real-world trends in treatment for US patients hospitalized with COVID-19, stratified by whether patients required invasive ventilation. Methods US patients diagnosed and hospitalized with COVID-19 between March 23 and December 31, 2020, in the Optum de-identified COVID-19 electronic health record (EHR) data set were identified. Both drug and procedure codes were used to ascertain medications, and both procedure and diagnostic codes were used to detect invasive ventilation during hospitalization. Medication trends were estimated by computing proportions of hospitalized patients receiving each drug weekly during the study period. Results In this cohort of 71,366 hospitalized patients, the largest observed change in care was related to chloroquine/hydroxychloroquine (HCQ) (Figure). HCQ usage peaked at 87% of patients receiving invasive ventilation (54% without ventilation) in the first week of this study (March 23-29), but declined to < 5% of patients, regardless of ventilation status, by the end of May. In contrast, dexamethasone usage was 10% at baseline in patients receiving ventilation (1% without ventilation) and increased to a steady state of >85% of patients receiving ventilation ( >50% without ventilation) by the end of June. Similarly, remdesivir usage increased sharply from a baseline of 2% of patients and continued to rise to a peak of 79% of patients receiving invasive ventilation (44% without ventilation) in November before declining. Conclusion Meaningful shifts in treatments for US patients hospitalized with COVID-19 were observed from March through December 2020. A dramatic decline was observed for HCQ use, likely owing to safety concerns, while usage of dexamethasone and remdesivir increased as evidence of their efficacy mounted. Across medications, usage was substantially more prevalent among patients requiring invasive ventilation compared with patients with less severe cases. Disclosures Kelly Zalocusky, PhD, F. Hoffmann-La Roche Ltd. (Shareholder)Genentech, Inc. (Employee) Shemra Rizzo, PhD, F. Hoffmann-La Roche Ltd. (Shareholder)Genentech, Inc. (Employee) Devika Chawla, PhD MSPH, F. Hoffmann-La Roche Ltd. (Shareholder)Genentech, Inc. (Employee) Yifeng Chia, PhD, F. Hoffmann-La Roche Ltd (Shareholder)Genentech, Inc. (Employee) Tripthi Kamath, PhD, F. Hoffmann-La Roche Ltd (Shareholder)Genentech, Inc. (Employee) Larry Tsai, MD, F. Hoffmann-La Roche Ltd (Shareholder)Genentech, Inc. (Employee)

Perceptions of Higher Specialist Trainees and Fellows of the Proposed Sláintecare Consultant Contract and Implications for Workforce Planning in Ireland

To explore the perceptions of higher specialist trainees and fellows in Ireland with respect to the Irish Department of Health’s recent proposal to implement a drafted, non-negotiated, consultant contract under a new model for healthcare, termed the Sláintecare plan. A customized survey, incorporating multiple-choice and Likert-scale questions and a free-text option, was disseminated to doctors enrolled in Irish higher specialist training (HST) programmes and pre-consultant HST graduates (fellows). Responses were compiled and analysed. There were a total of 1109 respondents across all specialities. Trainees were particularly concerned regarding the Sláintecare contract’s potential impact on their abilities to engage in patient advocacy and provide optimal patient care in the future, the maintenance of specialist skillsets, their ownership of intellectual property and a stable location of the practice. Of respondents, 93.7% (1003/1070) indicated that they would consider working abroad rather than accept the proposed contract. This study highlights the perceptions and concerns of the higher specialist trainees and fellows of Ireland. A large proportion may emigrate rather than accept the Sláintecare proposals. Concerns exist surrounding the ability to advocate for patients, to provide patient care, the proposed working conditions and perceived potential to deskill under this contract’s terms.

305 Using Urology Specific Ward Round Sheets to Improve Clinical Documentation

Aim To improve the documentation of vital clinical information on the urology ward round. To prompt clinical staff to review antibiotics, venous thromboprophylaxis, patient observations, and formulate a plan in a structured format. Method A retrospective, cross-sectional analysis was performed on the urology ward to assess whether the following parameters were documented/accounted for during ward-round: date, time, NEWS score, antibiotics, venous thromboprophylaxis, and whether the entry was easily found in the medical notes. Following this, a urology-specific ward-round sheet was synthesised between the medical and nursing staff. This standardised sheet was easily identifiable in the notes and ensured all the above parameters were accounted for by prompting the note-taker to record them. Two months following introduction of this standardised ward-round sheet the same parameters were analysed on all the urology inpatients in the same retrospective, cross-sectional manner. Results Documentation of the NEWS score improved from 30% to 93% with the introduction of the ward-round sheet. Similarly, documentation of whether antibiotics were reviewed improved from 30% to 60%, and documentation of venous thromboprophylaxis improved from 20% to 53%. It was also noted that the ward-round entry was easier to find with the ward-round sheet. Conclusions Documentation of key clinical information is vital to ensure optimal patient care. Surgical ward-rounds can be quick paced and important considerations such as antibiotics and venous thromboprophylaxis may be missed. This simple intervention improved the documentation of the intended parameters. The next step is to alter and improve the ward-round sheet before re-auditing.

Imaging of benign cervicofacial vascular anomalies and associated syndromes

Cervicofacial vascular anomalies can result in morbidity, pain, and cosmetic concerns in affected individuals. Each anomaly has its own unique natural history, treatment, and associations with underlying genetic syndromes. For optimal patient care, it is important for the neuroradiologist to accurately recognize and characterize these entities to ensure appropriate treatment and management. In this review, we discuss the general characteristics, classifications, and imaging features associated with the most common vascular anomalies such as hemangiomas, arteriovenous malformations and fistulas, capillary malformations, venous malformations, and lymphatic malformations in the context of associated syndromes. Additionally, we discuss novel imaging techniques that aid in identifying these vascular anomalies.

Ongoing Self-review and Continuous Quality Improvement Among Family Medicine Residencies

Graduate medical education (GME) occurs during and is a crucial step of the transition between medical school and clinical practice. Residency program graduates’ abilities to provide optimal patient care, act as role models, and demonstrate excellence, compassion, professionalism, and scholarship are key elements and outcomes of successful GME programs. In order to create and maintain the training environment that leads to such outcomes, programs must continually review and revise their patient care and educational activities. Currently, compliance with accreditation standards as determined by individual specialties such as family medicine serves as a common and significant marker for program quality. Compliance with these requirements is necessary but not sufficient if faculty and residents want to achieve the goal of residency training in terms continually improving and optimizing the care they provide to their patients and communities. For overall program improvement to truly occur, the patient care, scholarship, and community activities of current residents and graduates must be assessed and used in program improvement activities. Appropriately applied to programs and using these assessments, quality improvement principles and tools have the potential to improve outcomes of patient care in residents’ current and future practice and improve programs in educating residents.

Impact and role of pulmonary embolism response teams in venous thromboembolism associated with COVID-19

Venous thromboembolism associated with COVID-19, particularly acute pulmonary embolism, may represent a challenging and complex clinical scenario. The benefits of having a multidisciplinary pulmonary embolism response team (PERT) can be important during such a pandemic. The aim of PERT in the care of such patients is to provide fast, appropriate, multidisciplinary, team-based approach, with the common goal to tailor the best therapeutic decision making, prioritizing always optimal patient care, especially given lack of evidence-based clinical practice guidelines in the setting of COVID-19, which potentially confers a significant prothrombotic state. Herein, we would like to briefly emphasize the importance and potential critical role of PERT in the care of patients in which these two devastating illnesses are present together.

Neuro-Oncology Clinical Debate: FDG PET to differentiate glioblastoma recurrence from treatment-related changes

The ability to accurately differentiate treatment related changes (i.e. pseudoprogression and radiation necrosis) from recurrent glioma remains a critical diagnostic problem in neuro-oncology. Because these entities are treated differently and have vastly different outcomes, accurate diagnosis is necessary to provide optimal patient care. In current practice, this diagnostic quandary commonly requires either serial imaging or histopathologic tissue confirmation. In this article, experts in the field debate the utility of 2-deoxy-2[ 18F]fluoro-D-glucose positron emission tomography (FDG PET) as an imaging tool to distinguish tumor recurrence from treatment-related changes in a patient with glioblastoma and progressive contrast enhancement on MR following chemoradiotherapy.

Commentary on Chaplain-Physician Interactions From the Chaplain’s Perspective: A Mixed Method Analysis

Gomez and her colleagues have presented a helpful study of the relationship of the chaplains in her health system to physicians which highlights several barriers to a well-integrated relationship and thus to more optimal patient care. We have seen these same barriers as we have consulted with health systems nationally and have also identified many best practices that mediate or even eliminate many of these barriers. This commentary describes some of what we have seen as chaplain-generated causes of those barriers and effective strategies that have been employed to overcome them. We also provide some resources for chaplains who wish to institute some of these best practices themselves.