Clinical Presentations and Outcomes of Patients Receiving Immune Checkpoint Inhibitors Presenting to the Emergency Department.

Immune checkpoint inhibitors (ICIs) are increasingly used in the treatment of cancer. Immune checkpoint inhibitors may cause a wide-range of autoimmune toxicities referred to as immune-related adverse events (irAEs). There is a paucity of data regarding the presentations and outcomes of patients receiving ICIs who seek care in an emergency department (ED). We performed a retrospective review of patients receiving an ICI who presented to a tertiary care ED between May 1, 2017, and April 30, 2018. Data including ED chief complaint, diagnosis, treatment, and disposition were collected along with baseline characteristics and diagnosis at the time of outpatient oncology follow-up. We report descriptive statistics summarizing the characteristics of the cohort. There were 98 ED visits identified among 67 unique patients. Immune-related adverse events were diagnosed in 16 (16.3%) cases. The most common chief complaints within the irAE group were gastrointestinal symptoms 10 (62.5%). Among the 16 confirmed irAE cases, the most common irAE diagnosed was colitis 9 (56.3%). Two (12.5%) patients with irAEs received corticosteroids during their stay in the ED, and 10 (62.5%) patients with irAEs required hospital admission. Emergency medicine providers documented consideration of an irAE in the differential diagnosis in 14.3% of all ED visits and in 43.8% of visits in which an irAE was ultimately diagnosed. Emergency providers should be familiar with ICIs given their expanding use and potential adverse effects to improve early recognition and patient outcomes in ED settings.

Use of an EHR-Integrated Point-of-Care Mobile Medical Photography Application in a Pediatric Emergency Department.

BACKGROUND: Mobile applications allow health care providers to capture point-of-care medical photographs and transfer them to the electronic health record (EHR). It is unclear how providers use these photographs or how they affect clinical care. OBJECTIVES: We aimed to understand the content, purpose, and outcomes of point-of-care medical photography performed in the pediatric emergency department (ED) at large academic medical center. METHODS: A retrospective chart review was conducted of patients <21 years of age who were seen in the ED and photographed between March 29, 2015 and July 1, 2017 using a secure smartphone application integrated with the EHR. Inter-rater agreement and reliability between the two reviewers was assessed for the first 50 charts, and any discrepancies in interpretation were resolved before proceeding with the remaining data abstraction. The documented rationale for photography, content of photographs, and outcomes were recorded. RESULTS: We identified 619 clinical encounters involving photographs of 605 patients who were eligible for inclusion. Skin was photographed in 499 (81%). The most common finding was rash (N = 177; 29%). Photos were of acceptable quality, with 569 (94%) achieving a score between 4 and 5 out of 5. The primary use of photography was documentation (N = 334; 54%), though teleconsultation was noted in 38 (6%). Nearly one-third (N = 187; 30%) of patients were seen in the ED or outpatient clinic for any reason within 2 weeks, and in 25 (13%), clinical notes explicitly referenced the initial photograph(s). In 53 (9%) cases, patients were photographed at a clinical visit in the subsequent 2 weeks, suggesting that photography was used to track changes over time. CONCLUSION: Documentation of findings using mobile point-of-care photography allows for high-fidelity documentation and facilitates continuity of care.

Measuring achievement goal motivation, mindsets and cognitive load: validation of three instruments' scores.

OBJECTIVE: Measurement of motivation and cognitive load has potential value in health professions education. Our objective was to evaluate the validity of scores from Dweck's Implicit Theories of Intelligence Scale (ITIS), Elliot's Achievement Goal Questionnaire-Revised (AGQ-R) and Leppink's cognitive load index (CLI). METHODS: This was a validity study evaluating internal structure using reliability and factor analysis, and relationships with other variables using the multitrait-multimethod matrix. Two hundred and thirty-two secondary school students participated in a medical simulation-based training activity at an academic medical center. Pre-activity ITIS (implicit theory [mindset] domains: incremental, entity) and AGQ-R (achievement goal domains: mastery-approach, mastery-avoidance, performance-approach, performance-avoidance), post-activity CLI (cognitive load domains: intrinsic, extrinsic, germane) and task persistence (self-directed repetitions on a laparoscopic surgery task) were measured. RESULTS: Internal consistency reliability (Cronbach's alpha) was > 0.70 for all domain scores except AGQ-R performance-avoidance (alpha 0.68) and CLI extrinsic load (alpha 0.64). Confirmatory factor analysis of ITIS and CLI scores demonstrated acceptable model fit. Confirmatory factor analysis of AGQ-R scores demonstrated borderline fit, and exploratory factor analysis suggested a three-domain model for achievement goals (mastery-approach, performance and avoidance). Correlations among scores from conceptually-related domains generally aligned with expectations, as follows: ITIS incremental and entity, r = -0.52; AGQ-R mastery-avoidance and performance-avoidance, r = 0.71; mastery-approach and performance-approach, r = 0.55; performance-approach and performance-avoidance, r = 0.43; mastery-approach and mastery-avoidance, r = 0.36; CLI germane and extrinsic, r = -0.35; ITIS incremental and AGQ-R mastery-approach, r = 0.34; ITIS incremental and CLI germane, r = 0.44; AGQ-R mastery-approach and CLI germane, r = 0.48 (all p < 0.001). We found no correlation between the number of task repetitions (i.e. persistence) and mastery-approach scores, r = -0.01. CONCLUSIONS: ITIS and CLI scores had appropriate internal structures and relationships with other variables. AGQ-R scores fit a three-factor (not four-factor) model that collapsed avoidance into one domain, although relationships of other variables with the original four domain scores generally aligned with expectations. Mastery goals are positively correlated with germane cognitive load.