Evaluation of virtual assessment

BackgroundThe study emerged from the necessity to reschedule an in-person long case examination to an online platform for Physician Associate students’ final clinical examination. The group had already experienced a delay in taking this clinical examination due to missing clinical hours, during Covid-19 restrictions. The aim of this study was to evaluate the experiences of students and examiners for a high stakes’ clinical examination online. Research suggests that the long case is the only clinical examination that promotes holistic assessment. However, a disconnect between the patient’s presence and the student in the virtual environment was a key finding in this study. Methods This was an evaluation research study, using the Context, Input, Process, Product (CIPP) model, which provided a framework to establish the effectiveness and/or success of an online format for a high stakes’ clinical examination. All students and examiners were invited to take part in virtual interviews. ResultsResults suggest that both students (n=5) and examiners (n=7) agree that, while the stress of a face-to-face examination was lessened for the student, this was balanced by a new stressor of potential internet problems. All agreed that a virtual setting for a high stakes assessment is not transferable, with both groups citing the lack of opportunities to ‘read the patient’ and ‘showcase their physical exam skills’ as challenging. Conclusions Our study suggests that, in the context of balancing the risks of the pandemic with graduating healthcare professionals, the online format was a success. The benefits cited included the preparation of students for real life situations in a clinical setting, with a healthcare system now more reliant on virtual consultations, and the capacity to offer increased opportunities for formative assessment of consultation and clinical reasoning skills. However, recommendations suggest that the long case could be planned so that student and patient are in the same setting to perform a ten-minute physical exam, confirming the finding that questions on ‘how to’ examine a patient are no substitute for ‘doing’.

Unnecessary Chest Tube for a Hemodialytic Patient with Multiple Trauma: A Case Report

Background Pneumothorax (PTX) is a life-threatening condition that overdiagnosis could result in increases in mortality and morbidity of patients, this overdiagnosis would be increased if physicians do not manage the patient classically and do not pay attention to the physical exam and history of the patient. Case presentation: A-71-year old man was admitted to the emergency department due to multiple trauma. His vital signs were stable and in examination, there were two lacerations on his scalp with venous bleeding source and galea transaction; there were also some abrasions all over his body including his thorax. In the physical exam, there was no sucking lesion, decreases in respiratory sounds in auscultation or chest deformity but he had little right hemithorax rib tenderness. In more evaluations, there was a suspected visceral line of pleura in his CXR and no plural sliding movement was seen in E-FAST by the operator. Due to the inconsistency in physical exam and radiologic findings we decided to take a chest CT-scan before the insertion of the chest tube that indicated no PTX for him and the suspected visceral line in CXR was skin fold of a permacath for hemodialysis. Conclusions Several conditions could mimic findings of PTX in CXR that every physician should know and pay attention to them besides special attention to the history taking and physical examination to reduce the mortality and morbidity of patients.

Virilizing Adrenocortical Carcinoma Resected With Negative Margins Treated With Surgery Alone

Adrenocortical carcinoma is a rare malignancy. A virilizing adrenocortical carcinoma is even more unique of a diagnosis. In this report, we present a rare case of this uncommon tumor with an interesting presentation, clearly documented physical exam changes over a span of at least 8 years, and a technically challenging case. We also briefly review the management of adrenocortical carcinoma. The tumor was successfully resected with no planned adjuvant treatment at this time. The patient had recurrence of menstrual cycle post-operatively and required no steroid supplementation.

The Telemedicine Experience for Individuals with Sickle Cell Disease

Introduction Individuals with Sickle Cell Disease (SCD) require regular, and specialized treatment to manage their health. The COVID-19 pandemic disrupted in person medical visits for all individuals, with a rapid transition to telemedicine to provide medical care. Emerging data shows that the use of telemedicine may provide easier access to care and remove barriers to clinic attendance and improve access to appropriate medical care. Objective The purpose of this study was to use qualitative methods to understand the patients' experiences with telemedicine, identify patient preferences for type of appointment, and possible suggestions to improve telemedicine care. Methods Patients from the Johns Hopkins Sickle Cell Center for Adults who had at least one telemedicine visit were invited to participate in a semi structured interview via zoom meeting or telephone. The interview asked participants about their satisfaction with telemedicine care, barriers to telemedicine, benefits and risks of telemedicine and possible telemedicine improvements. Interviews were recorded, transcribed and coded by two independent raters using thematic analyses to understand the experiences of telemedicine during the COVID-19 pandemic. Results Overall, 30 adults with SCD who had at least one telemedicine visit were invited to participate and completed their interview (mean age 41 years ± xx, 67% female, 93% Black/African American, 3% Multi-Race, 3% Other). "...I can't ignore the convenience of not having to worry about transportation ... that there's nothing to stop me from getting there." During a SCD pain crisis it can it challenging to move and receive treatment as one participant reported "Maybe sometimes I might have pain...then moving around makes it difficult. So, getting in the car and finding somebody to drive you to a hospital or to whatever clinic would be difficult". Being able to access specialized SCD care even while in pain is important. Having the option of either having telemedicine or in person visits was important to SCD patients "I could treat my crisis here at home. I don't have to go to the emergency room for it. So, if I can see my doctor in the tele-visit appointment and it's going to be constantly every day ... And when it's getting worse, then I could go to the emergency room more if needed. If it's not needed, I don't even need to go". Another emerging theme amongst participants was despite the benefits from telemedicine, they also wanted to continue having in-person visits when they needed. SCD participants felt due to their SCD they still needed to see their doctor in person but it did not have to be for every visit "Well, I think telemedicine, for me, can be used in a setting where there's no such an emergency. Like if I'm having a routine exam, I don't mind having the telemedicine. But if ... I'm not feeling well ... I don't want to be having a telemedicine". SCD participants felt they needed a physical exam periodically. "The only thing I didn't like about it was if I'm having some discomfort or some pain... there was no way for the physician to physically examine me". Along with the lack of physical exam, there were concerns about the lack of vital signs "... the drawbacks would be the lack of the vitals being taken or there's not the personal touch and stuff". Conclusion The COVID-19 pandemic has presented many obstacles for patients to receive care. People living with SCD found telemedicine to be a positive tool to receive treatment. Patients reported the desire to continue with telemedicine even after the COVID -19 pandemic. Telemedicine allows for more accessibility for a group of individuals who already have numerous barriers to treatment. Future research can seek to identify the impact that telemedicine has on no-show rates, health care utilization, and the impact telemedicine has on patient reported quality of life. Disclosures Lanzkron: Teva: Current holder of individual stocks in a privately-held company; Shire: Research Funding; GBT: Research Funding; CSL Behring: Research Funding; Novo Nordisk: Consultancy; Bluebird Bio: Consultancy; Pfizer: Current holder of individual stocks in a privately-held company; Imara: Research Funding; Novartis: Research Funding.

56. High Frequencies of Adverse Drug Events with Intravenous vs Oral High-Dose Trimethoprim-Sulfamethoxazole: An Opportunity for Antibiotic Stewardship

Background Trimethoprim-sulfamethoxazole (TMP-SMX) is a high-bioavailability antibiotic associated with potentially serious adverse drug events (ADE). The objective of this study was to evaluate the safety of intravenous (IV) and oral (PO) high-dose TMP-SMX. Methods IRB-approved retrospective cohort of hospitalized patients from January 2016 to November 2020. Inclusion: ≥ 18 years old and > 72 hours of renally adjusted high-dose TMP-SMX defined as ≥ 5 mg/kg/day of TMP. Exclusion: prophylaxis. Endpoints during treatment: hyponatremia with sodium < 135 mmol/L, hyperkalemia with potassium > 5 mmol/L, serum creatinine increase of ≥ 0.3 mg/dL or 1.5-1.9 times from baseline, and fluid overload on physical exam. Descriptive and bivariate statistics were performed. Results Each group included 50 patients (Table 1). Intensive care unit patients comprised 82% IV TMP-SMX compared to 32% PO. Most common infection: respiratory tract 86% IV and 68.1% PO. Most common organisms were Stenotrophomonas maltophilia (52% IV and 18% PO) and Pneumocystis jiroveci (16.3% IV and 62% PO). Median (IQR) days of inpatient therapy: 6 (5-7.5) PO vs. 7.5 (6-11.3) IV. Median (IQR) days of total duration: 9 (6-21.5) PO vs. 12 (7.8-14) IV (p=0.93). IV group: 88% of patients received >1 liter of D5W daily. Median (IQR) liters of D5W daily was 1 (1-1.5). 56% had a diuretic added, and 38% had a diuretic dose increase. Majority of patients (78%) on IV were taking other oral medications. 100% patients experienced any adverse event with IV vs. 70% with PO (unAdjOR 2.43; 95% CI 1.89-3.13). Most common ADE in both groups: hyponatremia, hyperkalemia, and elevated creatinine. Hyponatremia: 92% with IV and 32% with PO (unAdjOR 24.44; 95% CI 7.50-79.68). Edema on physical exam, an ADE specific to IV TMP-SMX, was the third most common side effect in the IV group. Relative changes from baseline in sodium, potassium, and creatinine from those who experienced hyponatremia, hyperkalemia and elevated creatinine were listed in Table 2. Table 1. Baseline and Clinical Characteristics Table 2. Adverse Effects Conclusion Patients on IV TMP-SMX therapy were more likely to experience an ADE compared to PO, likely driven by the high volume of free water. Most patients on IV TMP-SMX were on other PO medications, suggesting a missed stewardship opportunity for IV to PO conversion to reduce patient harm. Disclosures Susan L. Davis, PharmD, Nothing to disclose Michael P. Veve, Pharm.D., Cumberland (Grant/Research Support)Paratek Pharmaceuticals (Research Grant or Support) Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder)