A Point-of-Care Interactive Decision Tool Reveals Variance Between Clinicians and Experts in Selecting Among GLP-1 RAs in T2D

Background: T2D management is shifting toward treating patients with therapies that align with their level of CV and end-organ risk. To this end, evidence-based guidelines now recommend glucagon-like peptide-1 receptor agonists (GLP-1 RAs) for both glycemic and extraglycemic benefits. The great speed with which these recommendations change create immediate gaps in knowledge and competence, especially as they relate to managing patients with comorbid CV and/or renal disease. To help clinicians understand GLP-1 RA therapies and their novel characteristics in practice, we developed a decision support tool where choice of treatment among GLP-1 RAs is guided by a panel of experts. Methods: We developed a decision support tool with guidance from 5 experts who provided therapy recommendations for 48 unique patient case scenarios based on patient variables including CVD, CKD, retinopathy, A1C level, and need for weight loss. Clinician learners are prompted to specify a patient scenario using these variables before selecting an intended therapy. After all questions are completed for a patient scenario, the tool displays what the panel of experts recommend and then asks the learner if this information changed their intended choice. Results: From February through October 2020, 983 learners entered 1433 unique patient case scenarios. Of these, 365 were anonymous and 623 were authenticated, of which 70% (n = 437) were from the US; 50% (n = 310) were MDs; 22% (n = 135) were nurses, NPs, or PAs; and 19% (n = 121) were PharmDs. The intended therapy of learners differed from the experts in 34% (n = 489) of cases and were limited to 3 categories: cases in which learners chose to use exenatide (17%), cases in which they chose to use a GLP-1 RA in conjunction with insulin (12%), or cases in which they were unsure (71%). Of note, of the 93 cases in which learners chose exenatide, 68% (n = 63) were cases with CVD and/or CKD, where exenatide was not recommended by experts. Similarly, of the 89 cases in which learners chose insulin with a GLP-1 RA, 57% (n = 51) were cases with A1C < 9%, where insulin was not recommended by experts. Of cases in which learners’ intended therapy differed from the experts’ (and they indicated the impact of the tool), 52% indicated that they planned to change their treatment plan. Conclusion: This tool highlights continuing gaps in clinicians’ ability to select among GLP-1 RAs for T2D. Using a decision support tool can positively influence practice behaviors: Learners can see if their intended treatment choice is congruent with a panel of experts and change plans as appropriate.

484 Solriamfetol Titration & AdministRaTion (START): Physician titration strategies in a hypothetical patient with narcolepsy

Introduction Solriamfetol (Sunosi®), a dopamine/norepinephrine reuptake inhibitor, is approved (US and EU) to treat excessive daytime sleepiness (EDS) in adults with narcolepsy (75–150 mg/day) or obstructive sleep apnea (OSA) (37.5–150 mg/day). Patient characteristics, comorbidities, and other EDS medications can influence treatment strategies. To understand factors physicians consider when initiating solriamfetol, this study analyzed titration strategies for a hypothetical patient. Methods This virtual, descriptive, cross-sectional, qualitative survey enrolled US-based physicians treating patients with EDS due to OSA and/or narcolepsy. Responses to 4 open-ended questions regarding a hypothetical patient were recorded. Patient scenario: 32-year-old woman with narcolepsy (Epworth Sleepiness Scale score=8) using an amphetamine stimulant (35 mg/day) and sodium oxybate (6 g/night) for 6 months and occasionally experiencing non-use-limiting but bothersome adverse events (AEs) with the stimulant. Content analysis of the recordings identified themes in the responses; a trained linguist captured language choices/patterns. Results Twenty-six physicians (neurologists, n=7 [27%]; internists/family practitioners, n=7 [27%]; pulmonologists, n=6 [23%]; psychiatrists, n=5 [19%]; otolaryngologists, n=1 [4%]) representing 781 patients on stable solriamfetol doses participated; 19 (73%) were board-certified in sleep disorders. Physicians had been treating narcolepsy a mean 15.7±6.6 years. Most (21 [81%]) thought the patient appropriate for solriamfetol, 3 (12%) thought not appropriate, and 2 (8%) thought appropriateness depended on other factors. Sixteen physicians (62%) suggested adjusting her stimulant, 3 (12%) the stimulant and sodium oxybate, and 1 (4%) neither. Nineteen (73%) would titrate solriamfetol per the label, with 13 (50%) aiming for 75 mg/day and 8 (31%) for 150 mg/day. Physicians emphasized stopping the stimulant before starting solriamfetol: 10 (39%) would taper down before starting solriamfetol, 7 (27%) while starting solriamfetol, and 1 (4%) while aiming to eventually switch; 8 (31%) would discontinue abruptly. Nineteen physicians (73%) would not change their approach if the stimulant dose were 60 mg/day. Most clinicians would change their approach if AEs occurred while starting solriamfetol by taking a slower or more gradual approach, while some would titrate off the stimulant more aggressively. Conclusion Physicians considered existing medications and potential AEs in their titration strategy when initiating solriamfetol. Support (if any) Jazz Pharmaceuticals

Current COVID-19 Pandemic and Medical Education: Medical Students' Perception and Experiences with Online Clinical Teaching and Learning at College of Medicine in Oman

Background: Clinical teaching is a form of interpersonal communication between a teacher and learner. It mainly involves a patient or a patient scenario; the student learns how to evaluate a patient and manage the problem. The ideal clinical teaching and learning are done in the patient care area, but because of the COVID-19 pandemic outbreak, all clinical and classroom teaching is suspended now.Objective: This study's main purpose was to assess medical students' perceptions and experiences with online clinical teaching and learning.Method: A cross-sectional study was conducted at the College of Medicine and Health Sciences (CoMHS). All students in 6 and 7 years consented to participate in the survey for a self-filled study (google form). Statistical analysis was performed using Statistical Package for Social Sciences (IBM SPSS Statistics 24.0). Data were expressed in frequencies for questionnaire responses calculated for all variables in numbers and percentages. Independent sample t-test was used to compare differences between two groups. Result: Ninety-one students participated in the study, of which 10.2% were male, and 46.2% were Omani citizens. 27.5% of students were 6th year, and 72.5% were 7th-year students. 69.2% of students did not experience any login/registration problem in GoToWebinar most of the time. Table 1 shows the student's responses in this regard. A significant statistical difference (p- <0.001; 95 % CI: 0.34-0.91) was observed between 6th year (mean-2.79±0.62) and 7th year students (mean-2.16±0.51). Conclusion: Medical students have shown a positive attitude and motivation towards webinar clinical teaching. Online webinar teaching can offer more diverse and compelling educational opportunities. Medical students in clinical years are self-directed learners but need in-depth learning with maximum hands-on practice. The Webinar teaches an impact on medical student education, particularly affecting the hands-on approach and training, which is limited and mandatory to become a doctor.

The Development of a Virtual World Problem-Based Learning Tutorial and Comparison With Interactive Text-Based Tutorials

Collaborative learning through case-based or problem-based learning (PBL) scenarios is an excellent way to acquire and develop workplace knowledge associated with specific competencies. At St George's, University of London we developed an interactive online form of decision-based PBL (D-PBL) for our undergraduate medical course using web-based virtual patients (VPs). This method of delivery allowed students to consider options for clinical management, to take decisions and to explore the consequences of their chosen actions. Students had identified this as a more engaging type of learning activity compared to conventional paper-based/linear PBL and demonstrated improved exam performance in controlled trials. We explored the use of Second Life (SL), a virtual world and immersive 3D environment, as a tool to provide greater realism than our interactive image and text-based D-PBL patient cases. Eighteen separate tutorial groups were provided with their own experience of the same patient scenario in separate locations within the virtual world. The study found that whilst a minority of students reported that the Second Life experience felt more realistic, most did not. Students favored the simpler interaction of the web-based VPs, which already provided them with the essential learning needed for practice. This was in part due to the time proximity to exams and the extra effort required to learn the virtual world interface. Nevertheless, this study points the way towards a scalable process for running separate PBL sessions in 3D environments.

115 Multi-Disciplinary Simulation Training on Delirium

Introduction Delirium is still perceived as a “geriatric medicine competency”, despite its high prevalence across most specialties. Collective multi-disciplinary team performance in implementation of multi-component interventions is key. Simulation training incorporates the complex interplay of non-technical factors, specifically, role recognition and empowerment, inter-personal skills and teamwork that are pivotal in delivering effective delirium care. Methods Funding was approved by Health Education England. 2 pilot teaching sessions were arranged in the simulation ward. 3 scenarios were developed, each requiring a facilitator, an actor and three participants- a foundation-year doctor, a nurse/healthcare assistant and a therapist. Scenario 1 dealt with a patient with hypoactive delirium with focus on identification and multidisciplinary optimisation. Scenario 2 challenged participants with management of an agitated patient. Scenario 3 involved discharging a patient with resolving delirium and a reluctant relative, with emphasis on mental capacity assessment. Communication, patient risk assessment and challenging perceived role barriers were global themes. Participant feedback was captured using unstructured interviews and pre- and post-session 5-point Likert confidence scale in various learning outcomes. Results 16 participants were included- 4 foundation year doctors, 3 therapists, 2 healthcare assistants and 7 nurses. There was an average improvement in Likert confidence scales in all measured learning outcomes. All participants would recommend the course to their colleagues (average Likert scale 4.9). Qualitative feedback appraised the course for demonstration of de-escalation communication strategies, the application of mental capacity and recognition of early discharge planning. Conclusion Simulation training targeted at multi-disciplinary groups is an effective way to deliver teaching on delirium. It contextualises synergistic operation of different skills and personal accountability in influencing patient management. The challenge to its potential remains its adoption as mandatory training for various disciplines involved in care of older adults and its implementation at a wider-scale, to assure cost effectiveness.

RETROSPECTIVE STUDY OF OPHTHALMIC CARE IN HIGH PROFILE PATIENT SCENARIO

BACKGROUND VIP syndrome is a condition in which high profile people are shown to experience adverse treatment effects even in the hands of skilled physicians or surgeons in absence of any other potentially complicating risk factor. High profile patients can be categorized into three groups: Public figures, Relatives, and Colleagues and other doctors. Since ophthalmological surgeries are micro surgeries requiring precise measurements and techniques, any secondary influence over the surgeon’s decision making powers, due to the presence of elite patients, has an undesirably affect. This is a retrospective analysis done after the surprising finding that correlates with many of my colleagues and we came to common conclusion about difference in approach towards known and unknown patients. METHOD 100 senior doctors belonging to different departments of a tertiary health care were inquired about their patients and the complications they faced while treating high profile patients by filling a questionnaire on the basis of their experience. RESULTS 90% of the doctors do categorize their patients into high profile patients, 80% of these doctors who faced complications had changed their routine treatment protocol. 93% of the doctors were cautious while treating these patients. 98% of the doctors agree with the bias present while treating high profile patients and consider the need to highlight VIP syndrome. CONCLUSION It is important to follow routine fixed protocol, no using new instruments or techniques and not to categorize any patient as high profile, manage such patients cautiously but without getting overcautious and maintaining confidentiality and privacy

Breastfeeding in women living with tuberculosis

Breast milk provides optimal nutrition, and is recommended for neonates and infants. In women with TB, there has been uncertainty about optimal feeding practices due to the risk of transmission to the neonate and the possibility of drug exposure via breast milk. For women who have drug-susceptible TB (DS-TB) who are no longer infectious, it is safe to breastfeed as breast milk does not contain Mycobacterium tuberculosis bacilli and only minor, non-toxic quantities of the drugs pass into breast milk. Most guidelines therefore encourage breastfeeding in women with DS-TB. However, there is uncertainty and guidelines vary regarding women with DS-TB who are still infectious and in women with rifampicin-resistant TB (RR-TB). Although the transmission dynamics of DS- and RR-TB are similar, additional infection control precautions for RR-TB may be necessary until the mother is responding to treatment, as second-line therapy may be less efficacious and preventive therapy is not widely offered to infants. In addition, there are no published data describing the extent to which second-line drugs are secreted into breast milk or subsequent exposure in breastfed infants. The implications of limited information on policy and consequent dilemmas regarding patient care are illustrated in a patient scenario. Areas for future research are suggested.

Relationship Between “Simulated Patient Scenarios and Role-Playing” Method and OSCE Performance in Senior Anesthesiology Residents: A Correlation Assessment Study

Background: “Simulated-patient scenarios and role-playing” and OSCE are among the many non-traditional education methods with variable results in different clinical settings. Objectives: This cross-sectional study was performed to assess the correlation between the results of these two methods in senior anesthesiology residents, with a special focus on four of the six ACGME core competencies. Methods: During two years, senior anesthesiology residents were subject to “simulated patient scenario and role-playing” sessions. Two faculty members took the role of the patient and one of the relatives. An objective checklist with 15 items was prepared to be rated by other department faculty members. Meanwhile, an ordered pattern of OSCE was prepared to cover four core competencies that were more related to this academic process (from a total of six core competencies). The mean and standard deviation of the score of each of the 15 items in the checklist were calculated. The correlation between cumulative checklist scoring results and OSCE exam results was assessed. A P value of less than 0.05 was considered significant. Results: A total of 40 senior anesthesiology residents, with 344 assessments by faculty members in 40 sessions, were enrolled in the study. The questionnaire’s Cronbach’s alpha reliability was 0.74. No statistically significant disparity was detected between the results of the two assessment methods, while the results of the two assessments had a significant correlation (two-tailed correlation coefficient = 0.886; P value < 0.001). Conclusions: There was an objective relationship between the results of “simulated patient scenario and role-playing” strategies and the results of OSCE exams using an observer-based rating method. Thus, they could be used as surrogates in the assessment of core clinical competencies of senior anesthesiology residents.

Exceptional Fertility and Poor Fetal Outcome in a Female with 17-Year Hemodialysis: A Case Study and Mini-review

Background: Chronic kidney disease can affect different aspects of female patient’s life including menstrual pattern, marital status and sexuality, fertility, pregnancy outcome, and recommended methods of contraception especially when initiated on HD. In Egypt, it has been noticed that it is infrequent for a hemodialysis (HD) female to start her marriage after initiation of HD; this may be attributed to a negative self-image experienced by the patient and perceived by the community. Moreover, it is also less common for an HD patient to marry another HD partner and it is odd for them to conceive during HD. Aim: To describe the possibility of starting family and plan for successful pregnancy during the course of HD therapy in patients with ESRD. Patient Scenario: Our case is a 36 years old Egyptian female who started HD in 1999 and continued on HD for 17 years. She married four times and conceived five times from three husbands. She got live birth only once from her second HD husband, but unfortunately, the baby died within a few days. The patient used Implanon - with its possible side effects- as a method of contraception during her last four years of life. After hectic 17 years under HD and unfortunate marital and fertility events, she decided to withdraw from her dialysis program, chose to live in isolation, and passed away within five days as a consequence of cerebral hemorrhage. Results and Conclusions: Fertility and successful pregnancies are believed to be possible in HD couples if they receive proper care.

Learning to predict pain: differences in people with persistent neck pain and pain-free controls

Background Learning to predict threatening events enables an organism to engage in protective behavior and prevent harm. Failure to differentiate between cues that truly predict danger and those that do not, however, may lead to indiscriminate fear and avoidance behaviors, which in turn may contribute to disability in people with persistent pain. We aimed to test whether people with persistent neck pain exhibit contingency learning deficits in predicting pain relative to pain-free, gender-and age-matched controls. Method We developed a differential predictive learning task with a neck pain-relevant scenario. During the acquisition phase, images displaying two distinct neck positions were presented and participants were asked to predict whether these neck positions would lead to pain in a fictive patient with persistent neck pain (see fictive patient scenario details in Appendix A). After participants gave their pain-expectancy judgment in the hypothetical scenario, the verbal outcome (PAIN or NO PAIN) was shown on the screen. One image (CS+) was followed by the outcome “PAIN”, while another image (CS−) was followed by the outcome “NO PAIN”. During the generalization phase, novel but related images depicting neck positions along a continuum between the CS+ and CS− images (generalization stimuli; GSs) were introduced to assess the generalization of acquired predictive learning to the novel images; the GSs were always followed by the verbal outcome “NOTES UNREADABLE” to prevent extinction learning. Finally, an extinction phase was included in which all images were followed by “NO PAIN” assessing the persistence of pain-expectancy judgments following disconfirming information. Results Differential pain-expectancy learning was reduced in people with neck pain relative to controls, resulting from patients giving significantly lower pain-expectancy judgments for the CS+, and significantly higher pain-expectancy judgments for the CS−. People with neck pain also demonstrated flatter generalization gradients relative to controls. No differences in extinction were noted. Discussion The results support the hypothesis that people with persistent neck pain exhibit reduced differential pain-expectancy learning and flatter generalization gradients, reflecting deficits in predictive learning. Contrary to our hypothesis, no differences in extinction were found. These findings may be relevant to understanding behavioral aspects of chronic pain.