ESOFAGITIS NECROTIZANTE AGUDA (ENA): REPORTE DE CASO

Introducción: La esofagitis necrotizante aguda (ENA) es una entidad patológica sumamente rara, cuya patogénesis no se ha identificado hasta la actualidad, pero se la asocia con la hipoperfusión tisular en pacientes de la tercera edad con antecedentes de patologías cardiovasculares (CV) o metabólicas. La ENA es identificada por endoscopia digestiva en ciertos pacientes con antecedentes de riesgo CV, quienes han presentado sintomatología como sangrado digestivo alto, disfagia súbita, epigastralgía intensa, vómitos, entre otros. Objetivo: describir un caso clínico de esofagitis necrotizante aguda, una entidad clínica poco estudiada, el manejo y la evolución clínica de la paciente. Caso clínico: paciente de 87 años con antecedentes de diabetes e hipertensión arterial, ingresada al Servicio de Medicina Interna por descompensación glicémica, quien en su estancia hospitalaria presentó disfagia súbita por lo que se realizó endoscopía digestiva alta, encontrándose un cuadro compatible con esofagitis necrotizante aguda, fue manejada con dieta absoluta, nutrición parenteral total, hidratación e inhibidores de la bomba de protones, siendo su evolución satisfactoria. Conclusiones: Se debería sospechar de ENA en pacientes adultos mayores quienes presentan sintomatología esófago-gástrica aguda y comorbilidades asociadas. Palabras clave: enfermedades del esófago, esofagitis, endoscopia, estenosis esofágica ABSTRACT Introduction: Acute necrotizing esophagitis (ENA) is an extremely rare pathological entity, the pathogenesis of which has not been identified to date, but it is associated with tissue hypoperfusion in elderly patients with a history of Cardiovascular disease (CVD) or metabolic pathologies. ENA is identified by digestive endoscopy in certain patients with a history of CVD risk, who have presented symptoms such as upper gastrointestinal bleeding, sudden dysphagia, intense epigastric pain, vomiting, among others. Objective: to describe a clinical case of acute necrotizing esophagitis, a little-studied clinical entity, the management and the clinical evolution of the patient. Clinical case: 87-year-old patient with a history of diabetes and arterial hypertension, admitted to the Internal Medicine Service due to glycemic decompensation, who during his hospital stay presented sudden dysphagia for which an upper gastrointestinal endoscopy was performed, finding a picture compatible with acute necrotizing esophagitis, was managed with absolute diet, total parenteral nutrition, hydration and proton pump inhibitors, and her evolution was satisfactory. Conclusions: ENA should be suspected in older adult patients who present acute esophageal-gastric symptoms and associated comorbidities. Keywords: diseases of the esophagus, esophagitis, endoscopy, esophageal stricture

Addressing Transportation Insecurity Improves Attendance at Posthospitalization Appointments

BACKGROUND: Transportation influences attendance at posthospitalization appointments (PHAs). In 2017, our pediatric hospital medicine group found that our patients missed 38% of their scheduled PHAs, with several being due to transportation insecurity. To address this, we implemented a quality improvement project to perform inpatient assessment of transportation insecurity and provide mitigation with the goal of improving attendance at PHAs. METHODS: The process measure was the percentage of patients with completed transportation insecurity screening, and the outcome measure was PHA attendance. An interprofessional team performed plan-do-study-act cycles. These included educating staff about the significance of transportation insecurity, its assessment, and documentation; embedding a list of local transportation resources in discharge instructions and coaching families on using these resources; notifying primary care providers of families with transportation insecurity; and auditing PHA attendance. RESULTS: Between July 2018 and December 2019, electronic health record documentation of transportation insecurity assessment among patients on the pediatric hospital medicine service and discharged from the hospital (n = 1731) increased from 1% to 94%, families identified with transportation insecurity increased from 1.2% to 5%, and attendance at PHAs improved for all patients (62%–81%) and for those with transportation insecurity (0%–57%). Our balance measure, proportion of discharges by 2 pm, remained steady at 53%. Plan-do-study-act cycles revealed that emphasizing PHA importance, educating staff about transportation insecurity, and helping families identify and learn to use transportation resources all contributed to improvement. CONCLUSIONS: Interventions implemented during the inpatient stay to assess for and mitigate transportation insecurity led to improvement in pediatric PHA attendance.

Analysis of Organizational Models of Disaster Medicine Service of the Ministry of Health of the Russian Federation at Regional Level

The results of study and analysis of organizational and functional changes in the Disaster Medicine Service of the Ministry of Health of Russia at the regional level, organizational models of the Disaster Medicine Service functioning in the subjects of the Russian Federation are presented. The study was conducted at the All-Russian Center for Disaster Medicine “Zashchita” (since 2015) and at the Federal Center for Disaster Medicine of the National Medical and Surgical Center named after N.I. Pirogov of the Ministry of Health of Russia. The purpose of the study is to analyze organizational models of the Disaster Medicine Service functioning at the regional level. Materials and research methods. The following methods were used in the study: expert evaluation, statistical, analytical, field observation, etc. The method of expert evaluation was applied through questionnaire survey of experts – Russian experts in the field of disaster medicine and emergency medical care. The questionnaires were filled in twice – questionnaire №1 – in 2015 and questionnaire №2 – in 2019-2020; a total of 529 people took part. Questionnaires № 1 and № 2 included questions and provisions relating to organizational models of the Disaster Medicine Service functioning at the regional level and to organizational and functional changes in the Disaster Medicine Service of the subjects. Results of the study and their analysis. The results of the research helped to formulate a number of principle statements on further improvement of the Disaster Medicine Service, including development of organizational structure, implementation of its organizational models at the regional level.

On the Issue of Special Exercises in the Counterterrorism System Involving Specialists of Health Care Management Bodies, Medical Formations and Organizations

The objectives of the study are to analyze the experience of exercises conducted in the counter-terrorism system by specialists of the regional Disaster Medicine Service, to identify key organizational issues of preparation and implementation of exercises; to develop proposals for their improvement in the subject of elimination of medical and sanitary consequences of terrorist acts committed with the use of conventional means of destruction. Materials and research methods. Sources of information and materials studied: normative and methodological documents regulating the procedures of organizing and conducting military training in the field of healthcare; materials of trainings performed by specialists from regional EMC on the subject of organizing the liquidation of medical and sanitary consequences of terrorist acts; data from expert evaluation maps on the subject of the study; scientific papers and publications on technologies of training and exercises involving specialists from healthcare management bodies, medical units and organizations. The following scientific methods were used in the research: content analysis method, expert assessment method, statistical method, logical and informational modeling, and analytical method. Results of research and their analysis. The results of the study of basic organizational issues of preparing and conducting special exercises (command-staff exercise, staff training, tactical and special exercises) conducted in the regions with the participation of specialists of public health authorities, medical formations and organizations within the framework of counter-terrorism are presented. Sound proposals were made to improve the technology of preparing and conducting special exercises and communicating their results to medical specialists. The results of the study showed that almost all the experts (98.0%) were in full agreement with the need, in order to maintain and increase the preparedness of health care authorities, medical organizations, including emergency medical care and the Disaster Medicine Service, to conduct regional trainings on the subject of medical support of the population during terrorist acts. And only 2.0% of the experts had difficulty in formulating a specific conclusion on this issue.

Providing high performance medical services to athletes in the Republic of Moldova

High-performance medical services means providing people who practice physical activity and sport with conditions for the organization of a periodic medical examination of their state of health, medical assistance during training and sports competitions, consultations on nutrition issues, rehabilitation services after traumatic injuries, educational activities for the promotion and maintenance of health. Th is paper includes a series of recommendations for strengthening the sports medicine service in the Republic of Moldova and ensuring its sustainability.

Mixed-methods evaluation of the NHS Genomic Medicine Service for paediatric rare diseases: study protocol

Background: A new nationally commissioned NHS England Genomic Medicine Service (GMS) was recently established to deliver genomic testing with equity of access for patients affected by rare diseases and cancer. The overarching aim of this research is to evaluate the implementation of the GMS during its early years, identify barriers and enablers to successful implementation, and provide recommendations for practice. The focus will be on the use of genomic testing for paediatric rare diseases. Methods: This will be a four-year mixed-methods research programme using clinic observations, interviews and surveys. Study 1 consists of qualitative interviews with designers/implementers of the GMS in Year 1 of the research programme, along with documentary analysis to understand the intended outcomes for the Service. These will be revisited in Year 4 to compare intended outcomes with what happened in practice, and to identify barriers and facilitators that were encountered along the way. Study 2 consists of clinic observations (pre-test counselling and results disclosure) to examine the interaction between health professionals and parents, along with follow-up interviews with both after each observation. Study 3 consists of a longitudinal survey with parents at two timepoints (time of testing and 12 months post-results) along with follow-up interviews, to examine parent-reported experiences and outcomes. Study 4 consists of qualitative interviews and a cross-sectional survey with medical specialists to identify preparedness, facilitators and challenges to mainstreaming genomic testing. The use of theory-based and pre-specified constructs will help generalise the findings and enable integration across the various sub-studies. Dissemination: We will disseminate our results to policymakers as findings emerge, so any suggested changes to service provision can be considered in a timely manner. A workshop with key stakeholders will be held in Year 4 to develop and agree a set of recommendations for practice.

Sickle Cell Disease (SCD) As a Risk for COVI19 Compared to Those without SCD Among Patients Admitted in a Large Urban Center, As Estimated By PCR Sars-v-2 Positive Vs Negative Testing

A diagnosis of SCD is considered to be at risk for COVD19. To further define the association between SCD and infection with COVID-19, we estimated risk, by comparing presence or absence of COVID19 infections in individuals with and without SCD admitted concurrently to a large urban health care facility (Grady Memorial Hospital, Atlanta, GA; 960 beds, 5th largest public hospital in the US). Primary outcome was a positive or negative COVID-19 diagnosis as defined bySARS-CoV-2 PCR testing. A patient was considered to be COVID-19 positive if tested positive withSARS-CoV-2 PCR for the first time, anytime during the study period, irrespective of number of tests. A patient was considered to be COVID-19 negative if patient had no positive tests during the study period, and had one or moreSARS-CoV-2 PCR negative tests. For COVID19 positive patients, the admission of theSARS-CoV-2 PCR positive test was included in the analysis. For COVID19 negative patients, the first admission with aSARS-CoV-2 PCR negative test was considered for analysis. For this interim analysis, SCD was defined by ICD10 and registry data. Clinical diagnosis such as obesity and respiratory failure were defined by ICD10 coding. Data was obtained from quarterly centralized Epic EMR data extractions. Analysis of outcome of COVID19 positive vs negatives was stratified in four separate analysis: all admissions, ICU admissions, those with respiratory failure and those who died. Multivariate dichotomous logistic regression analyses modeled binary outcome effect of SCD, adjusted for age (<40 vs. > 40 years), sex at birth (females vs. males) and obesity (SAS version 9.4 was used for statistical analyses and overall significance level was set at 0.05). To ensure population homogeneity analysis was conducted on patient ages 20 to 60 years that were Black/African American and admitted from the Emergency Department for a short stay and/or the medicine service (variable interactions at a p<0.01). The study was approved by the institutional review board and by the hospital research oversight committee. Overall, between 3/23/2020 and 6/30/2020, 23697 patients were admitted once or more to Grady Memorial Hospital with one or more PCR sars-cov-2 test, of these 405 were patients with SCD (1.7%). Of the total, 2566 patients (10.8%) tested positive for COVID-19, and 48 patients with SCD (11.8%) were positive. Of 7041 (29.7%) were part of the study population, 332 (4.7%) where patients with SCD (hemoglobin [hb] SS/Sbeta0 =252, hbSC n=55, hbS beta thalassemia+ or hbS beta thalassemia undetermined n=21). Among patients without SCD, 36.3% were female, (n=2557) and among patients with SCD, 53.6% (n=178). The mean age of patients without SCD was: 51.1 years (standard deviation [std]) +/- 19.5 years), and for those with SCD: 35.0 years (std +/- 12.0 years). Results of univariate and multivariate analysis are presented in the table. In conclusion, in a Black/African American patients admitted from the Emergency Room for observation and/or the internal medicine service, when adjusted for age, gender and obesity, with SCD are at a significant increased risk for admissions with COVID-19 infection in general as well as ICU admission or admission with respiratory failures. Further studies can help articulate the risk associated with SCD as well as its potential interaction with other factors, with attention to confounders. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

More than Means to an End: Assessing Surgical Provider Familiarity with Palliative Care

Background As palliative medicine concepts emerge as essential surgical education, there has been a resulting spike in surgical palliative care research. Historic surgical dogma viewed mortality and comfort-focused care as a failure of the providers’ endurance, knowledge base, or technical skill. Therefore, many providers avoided consultation to a palliative medicine service until it became evident a patient could not survive or was actively dying. As the need for surgical palliative care grows, the identification of deficits in surgical providers’ understanding of the scope of palliative medicine is necessary to direct further training and development efforts. Method A ten-question survey was emailed to all residents, physician assistants, nurse practitioners, and attending physicians in the general surgery and subspecialty surgical departments within the Einstein Healthcare Network. Results 30 non-trainees (attending surgeons, nurse practitioners, and physician assistants) and 26 trainees (PGY-1 to PGY-5) completed the survey. Less than half of participants reported training in conversations regarding withdrawal of life-prolonging treatments in the setting of expected poor outcomes, 55% reported receiving training in pain management, and 64% reported receiving training in delivery of bad news. 54% report being involved in five or more end-of-life discussions in the last year with trainees reporting fewer end-of-life discussions than non-trainees; 67% of trainees reported zero to four discussions while 23% of non-trainees reported over twenty discussions ( P = .009). Conclusions Despite many participants training in intensive care settings, providers lack the training to carry out major discussions regarding life-limiting illness, goals of care, and end-of-life independently.