Decreasing Headache Pain Secondary to a Subarachnoid Hemorrhage with the use of Osteopathic Manipulative Medicine

Background: Controlling a headache (HA) secondary to a subarachnoid hemorrhage (SAH) can be challenging for most physicians. At Maine Medical Center in Portland, Maine, the neurointensivist and staff noticed a trend in decreasing HA pain caused by a SAH in patients treated with osteopathic cranial manipulative medicine and osteopathic manipulative medicine (OMM), more so than those treated solely with the traditional opioid approach. It was requested that a chart review of these patients be evaluated for an objective analysis of this observation. Hypothesis: A decrease in HA caused by SAH will be observed in the group treated with OMM in comparison to those treated with opioids alone. Methods and Materials: A retrospective, IRB approved, and exempted study reviewed 21 subjects with a SAH that were treated with OMM. This population was analyzed for a decrease in pain score following osteopathic treatment as well as for adverse events 6-month post treatment. Results: Pain scores were consistently reduced when comparing pre-and-post OMM treatment. After the first treatment, pain scores decreased by an average of 4 points, after the second treatment scores decreased by an average of 3 points and after the third treatment pain scores decreased by an average of 2.5 points. The number of adverse events recorded were found to be less than the national averages. Conclusion: The use of OMM as an adjunct with traditional treatments for a SAH can lead to a decrease in HA pain caused by a SAH. Minimal adverse events were observed.

Vasopressin-Induced Hyponatremia in Patients With Aneurysmal Subarachnoid Hemorrhage: A Case Series and Literature Review

Objective Vasopressin may be administered to treat vasospasm following aneurysmal subarachnoid hemorrhage (aSAH). The objectives of this study were to describe five cases of suspected vasopressin-induced hyponatremia after aSAH and to review the literature. Design Single-center, observational case series of intensive care unit (ICU) patients Settings Ten-bed neurological ICU at Maine Medical Center in Portland, Maine Patients Convenience sample of patients with aSAH treated with a vasopressin for symptomatic, radiologically confirmed vasospasm Results A total of five patients were included in the case series with a median age of 57 (51, 65) years and all were women. The median Glasgow coma scale score was 15 (11, 15) on admission, and the Hunt and Hess scale score was 3, (3, 4). All patients were treated with endovascular coiling of their aneurysm. Vasopressin was administered to treat symptomatic, radiographically confirmed vasospasm on median post-bleed day (PBD) 10 (10, 15) at a fixed-dose of .03 units/min. Serum sodium at baseline was 140 (140, 144) mEq/L and decreased to 129 (126, 129) mEq/L within 26 (17, 83) hours of vasopressin initiation for a median change of −16 (−10, −16) mEq/L. Serum sodium returned to baseline within 18 (14, 22) hours of stopping the infusion. Conclusions Vasopressin use in vasospasm after aSAH may be associated with clinically significant hyponatremia within 24 hours of starting the infusion. Hyponatremia appears to resolve within 24 hours of stopping the infusion. Additional study in a larger sample size is needed to determine if a causal relationship exist.

Safety of ECT in patients receiving an oral anticoagulant

Introduction This study assessed the use, tolerability, and safety of anticoagulation via direct oral anticoagulants or warfarin in medical and psychiatric inpatients receiving ECT. Methods This retrospective cohort study included 32 patients who received ECT while on either a direct oral anticoagulant (9) or warfarin (23) and spanned 247 encounters at Maine Medical Center between December 2012 and December 2018. Data are presented descriptively and analyzed using SPSS version 25 and Microsoft Excel version 2016. Results Among the 247 ECT patient encounters, there were few major adverse effects of ECT in this medically complex population. These adverse effects included headache during 4 encounters (1.6%), respiratory distress during 2 encounters (0.8%) and a cardiovascular event during 1 encounter (0.4%). One patient (3.1%) who was receiving concurrent rivaroxaban and venlafaxine experienced gastrointestinal bleeding that was determined to be unrelated to ECT. One patient on fluoxetine and warfarin experienced hemoptysis thought to be secondary to epistaxis. No other major bleeding or clotting event occurred during an ECT session nor for the duration of the hospitalization. Discussion Direct oral anticoagulants and warfarin appear safe in the treatment of patients with atrial fibrillation or acute venous thromboembolism who are receiving concomitant ECT. Prospective studies are needed to confirm these findings.

Barriers to web-based symptom management systems (web-SyMS).

6545 Background: Web-SyMS can reduce the burdens of cancer and its treatment. While patients frequently express willingness to use these systems, only a subset actively engages with them. Some patients may lack the tools and confidence needed to benefit from web-SyMS. We sought to characterize these barriers among community-based cancer patients receiving care across six diverse healthcare systems. Methods: We surveyed patients receiving chemotherapy at three healthcare systems (Baptist, TN; Maine Medical, ME; Dana-Farber, MA) and patients recovering from cancer-directed surgery at three healthcare systems (West Virginia University, WV; Dartmouth-Hitchcock, NH; Lifespan, RI). Surveys were conducted as part of a pre-implementation analysis of eSyM – an EHR-embedded web-SyMS that collects, tracks, and manages patient reported outcomes during cancer therapy. Results: Among 563 respondents, access to tech devices (i.e., tablet, computer, or smartphone) was high: 78% reported access to ≥2 devices and only 5% reported access to no devices. However, confidence using tech devices to accomplish online tasks varied: 45% very confident, 38% somewhat confident, 11% little-no confidence. Compared to medical oncology patients, surgery patients were more likely to report being very confident (57% vs. 31%). There were significant differences based on patients’ self-reported tech confidence (Chi-square P<.05 for all values in the table). Conclusions: Low self-reported tech confidence may identify patients who are at high risk for experiencing the burdens of cancer but may be less likely to benefit from web-SyMS. Addressing this barrier is critical to improving outcomes and addressing disparities. Clinical trial information: NCT03850912. [Table: see text]

Abstract 13688: Shocking: Cardioversion in Cardiogenic Shock Has Limited Success

Introduction: Atrial fibrillation (AF) and atrial flutter (Aflutter) are common in cardiogenic shock patients in the Cardiac ICU (CICU). Electrical cardioversion (CV) can restore sinus rhythm, but carries the risk of transient hemodynamic deterioration. There has been little research in the efficacy and safety of electrical CV for AF/Aflutter in the CICU. Objective: Describe success of CV in AF/Aflutter in cardiogenic shock patients in the CICU. Methods: We identified Maine Medical Center CICU patients from 1/1/2015 to 12/31/19 who were in cardiogenic shock and underwent electrical CV for AF/Aflutter. Cardiogenic shock was defined by depressed cardiac index (<2.2L/m^2 or inotrope use), hypotension (systolic BP <90 mmHg, MAP <65 mmHg, or vasopressor use), and Lactate > 2mmol/L. If a patient had multiple CVs, only the first was analyzed. Results: Twenty patients met the inclusion criteria. Initially, 16 of 20 CVs were successful, however only 10 patients were in SR 24 hours after CV and only 7 were in SR at CICU discharge (Figure 1). The median LVEF was 20%, similar between groups (p-value = 0.52 initially, 0.37 at 24 hours, and 0.18 at CICU discharge). Only 1 patient was on mechanical support. The type of AF was varied (35% newly diagnosed, 55% paroxysmal, and 10% persistent). In patients with new AF, 85% were in SR initially, 57% at 24 hours, and 28% at CICU discharge. All patients received amiodarone. Inotrope use was similar, however no patients on vasopressors were in SR at CICU discharge (5/13 vs 0/7, p=0.11). Only 1 patient suffered an adverse effect (sinus bradycardia). Diabetes (p = 0.064) was the only characteristic to nearly predict lack of CV success at CICU discharge. Conclusions: 1. Electrical CV in patients admitted to the CICU in cardiogenic shock had a high initial success rate, however success was short-lived. 2. CV did not cause serious adverse effects. 3. Larger registries/trials are needed to predict which subgroups of CICU patients benefit from CV for Afib/Aflutter.

Redesigning the Clinical Learning Environment to Improve Interprofessional Care and Education: Multi-Method Program Evaluation of the iPACE Pilot Unit

ABSTRACT Background In 2016, Maine Medical Center received an Accreditation Council for Graduate Medical Education Pursuing Excellence in Innovation grant to redesign the clinical learning environment to promote interprofessional care and education. The Interprofessional Partnership to Advance Care and Education (iPACE) model was developed and piloted on an adult inpatient medicine unit as an attempt achieve these aims. Objective We describe the iPACE model and associated outcomes. Methods Surveys and focus groups were employed as part of a multimethod pragmatic observational strategy. Team surveys included relational coordination (RC): a validated proprietary measure of interpersonal communication and relationships within teams. Pre-iPACE respondents were a representative historical sample from comparable inpatient medical units surveyed from March to April 2017. iPACE respondents were model participants surveyed March to August 2018 to allow for adequate sample size. Results Surveys were administered to pre-iPACE (N = 113, response rate 74%) and iPACE (N = 32, 54%) teams. Summary RC scores were significantly higher for iPACE respondents (iPACE 4.26 [SD 0.37] vs 3.72 [SD 0.44], P &lt; .0001), and these respondents were also more likely to report a professionally rewarding experience (iPACE 4.4 [SD 0.6] vs 3.5 [SD 1.0], P &lt; .0001). Learners felt the model was successful in teaching interprofessional best practices but were concerned it may hinder physician role development. Patient experience was positive. Conclusions This pilot may have a positive effect on team functioning and team member professional experience and patient experience. Learner acceptance may be improved by increasing autonomy and preserving traditional learning venues.

4441 Comparing 3 methods of assessment of psoas area as a proxy for sarcopenia in predicting short-term outcomes in trauma patients 55 years and older

OBJECTIVES/GOALS: Specific Aim 1 To examine sex distribution of psoas cross sectional area (CSA) on CT imaging in a cohort of trauma patients age 55 and older. We will use three methods of assessing psoas CSA: psoas CSA averaged between left and right, average psoas CSA adjusted for height, and average psoas CSA adjusted for body surface area (psoas index). Specific Aim 2 Use multivariable logistic regression prediction modeling to compare the 3 methods of CT psoas muscle measurement widely used in the literature in their ability to predict a composite of in-hospital morbidity and mortality in trauma patients ages 55 and older. METHODS/STUDY POPULATION: The Maine Medical Center Trauma Registry is maintained by the Trauma Surgery Service at Maine Medical Center in Portland, Maine, the only Level-1 trauma center in the state. After receiving approval from the Institutional Review Board of Maine Medical Center for this retrospective cohort study, we queried the Maine Medical Center Trauma Registry for all adults 55 years and older who underwent evaluation by the Trauma Service between January 1, 2015 and January 1, 2019. In the case of multiple admissions within the study time period, only a patient’s index admission was used. MaineHealth IMPACS imaging software was used to measure bilateral psoas CSA on each patient CT. The Maine Medical Center electronic medical record was queried for additional clinical information including the ICD codes associated with each patient encounter. Data analysis was performed using R statistical software (R project, Vienna, Austria). Data is reported as median + IQR for CSA measurements. The agreement between the three methods of quantifying psoas CSA was evaluated using Pearson correlation (R package “stats”). Inter-rater reliability of psoas muscle measurements was evaluated using intra-class correlation (R package “irr”). Prediction models for the composite outcome of in-hospital morbidity and mortality were constructed using multivariable logistic regression. Bootstrapping was used for internal validation and shrinkage to avoid overfitting. Models including psoas CSA were compared to a baseline model without psoas CSA to evaluated incremental added predictive ability. RESULTS/ANTICIPATED RESULTS: This cohort provides a basis for examining the population distribution of psoas CSA in adults 55 years and older. IN addition to a high level of agreement between the three methods of measuring psoas CSA (Spearman coefficient > 0.9), there was also high level of inter rater reliability in psoas muscle assessment (intraclass correlation 0.9). We anticipate that psoas CSA adjusted for body surface area will add the most incremental predictive ability to a model predicting in-hospital morbidity and mortality. DISCUSSION/SIGNIFICANCE OF IMPACT: Given the heterogeneity of health status amongst elderly trauma patients, a major challenge lies in the rapid objective identification of those elderly trauma patients who are frail. Due to the limitations in current frailty measures, there has been a surge of interest in surrogate markers of frailty, such as muscle mass, as predictive factors of poor outcomes after trauma.Several studies have found that sarcopenia is associated with post injury morbidity and mortality. Estimates of the prevalence of sarcopenia among trauma patients vary across studies due to differences in definition and sample characteristics. In order to appropriately categorize patients as sarcopenic, the population distribution of psoas CSA on CT must be established. The psoas measurement that best correlates with outcomes has yet to be determined, and it is unclear which measurement should be implemented in usual practice. Our main objective is to improve the outcomes of sarcopenic patients hospitalized with trauma by implementing in the future patient-centered interventions which will account for sarcopenia.

Candida Infective Endocarditis During the Infectious Diseases and Substance Use Disorder Syndemic: A Six-Year Case Series

Treatment for Candida infective endocarditis (IE) has not been extensively studied in the setting of rising injection drug use. There were 12 cases of Candida IE at the Maine Medical Center between 2013 and 2018. The patient characteristics, treatment regimens, and outcomes were retrospectively analyzed.