BACKGROUND: Patients with inflammatory bowel disease (IBD) are often treated with biologic medications that require visits to an infusion suite. Due to the high cost of biologics, they are not mixed and released from the pharmacy until patient arrival. This typically leads to long wait times after patient check in. An investigator-developed novel smartphone application (app) titled Almost There was created to reduce wait times through the use of geofences to notify the infusion suite when patients are nearing their destination (the hospital). Our aim was to perform a pilot study to assess the feasibility of Almost There for patients with IBD coming for infusions at a rural academic medical center. METHODS: Adult patients with Crohn’s disease (CD) or ulcerative colitis (UC) currently receiving intravenous biologic therapy were recruited for this pilot study. Patients received instructions on how to download the app onto their smartphone. Patients activated the application prior to leaving their homes and answered standard screening questions to assess for active infections. Using geofences, the app automatically notified the infusion suite when the patient was within 10 miles of the hospital. The infusion suite alerted the pharmacy who immediately proceeded with medication preparation. Patients completed surveys upon arrival to the infusion suite collecting basic demographics and disease information, perceived wait times for that visit and previous visits prior to using the app. The infusion suite staff recorded actual wait times from check in to medication administration. RESULTS: The app was trialed successfully for 12 total visits among 9 patients (5 CD, 4 UC). 78% of app users were 25-44 years old and 22% were 45 years and older. 56% of patients were receiving infliximab and 44% were receiving vedolizumab. 11 patients were recruited and 9 patients out of 11 were able to successfully use the app. Reasons for app failure included one user who forgot their phone at home, one with loss of cell service, and one app malfunction. The median actual wait time from when patients arrived at the infusion suite to the start of the infusion was 38-40 minutes. In 67% of visits, there was decreased perceived wait time for patients using the app compared to their prior visits. When using the app, perceived wait times were shorter than actual wait times in 75% percent of patients. CONCLUSION: In this pilot feasibility study, the Almost There app led to decreased perceived wait times for IBD patients coming for biologic infusions. The application was not effective for 18% of patients for a variety of reasons. If this or a similar app was improved to allow for more consistent usability it should be studied compared to a control group to evaluate if it leads to decreased wait times for any medical infusion.

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Rural America spans about two-thirds of the land that composes the United States. There are major health disparities in this population including a lack of screening, a shortage in education, and limited access to health care providers. These health disparities combined with a lack of health insurance led our patient to ignore the asymptomatic melanoma on her right foot for 10 years. Although the most recent update from the US Preventive Service Task Force found insufficient evidence to recommend for or against routine melanoma and non-melanoma skin cancer screening, our patient insists that the screening she attended that day saved her life.

Panhypopituitarism is an extremely rare disorder in acute myeloid leukemia (AML) with only 6 cases previously reported to date. The mechanism of AML causing panhypopituitarism is unclear, but some of the leading hypotheses support leukemic infiltration or leukostasis. A 30-year-old incarcerated woman with a history of intravenous drug use and hepatitis C presented with 5 days of fevers, vomiting, and progressive abdominal pain. She reported an unintentional 30 lb weight loss and a month of polyuria and polydipsia severe enough to cause her to drink water from the dirty sink in her prison cell. Patient denied headache, visual disturbance, or galactorrhea. Initial laboratory studies showed a white blood cell count of 350K with 90% myeloblasts, consistent with AML. She received emergent leukocytapheresis and was started on cytarabine and daunorubicin chemotherapy. Upon admission, she was also noted to have hypernatremia (Na 152 mmol/L), persistent hypotension (BP 80s/40s) unresponsive to fluid resuscitation, and high urine output of 5-14 L/day. Desmopressin (DDAVP) 4 mcg IV was administered and resulted in increased urine osmolality from 116 to 451 mOsm/L with significant decrease in urine output, consistent with central diabetes insipidus (cDI). Brain MRI showed heterogeneous thickening of the infundibulum and an absence of the posterior pituitary T1 bright spot, which can be seen in cDI. Hormonal evaluation revealed low free T4 0.77 ng/dL (ref. 0.93-1.70) and normal TSH 4.03 mIU/mL (ref. 0.27-4.20), consistent with central hypothyroidism. Prolactin was mildly elevated at 39 ng/mL (ref. 4.8-23.3). She was also noted to have low AM cortisol 3 µg/dL (ref. 5-20) prompting a cosyntropin stimulation test which showed baseline cortisol of 5.9 rising to 13.2 µg/dL, which is an inadequate response. She was treated for panhypopituitarism with hydrocortisone 50 mg IV Q8H tapered gradually to a replacement dose, DDAVP 50 mcg PO QHS, and levothyroxine 50 mcg PO daily. Her remaining hospital course was complicated by neutropenic fever. She was ultimately transferred to Massachusetts General Hospital on hospital day 19 (Day 16 of chemotherapy) to be closer to her family. This is a rare case report of a young patient with new diagnosis of AML presenting with both cDI and panhypopituitarism. The mechanism remains unclear. One possible rationale is pituitary stalk involvement by leukemic infiltration which is evidenced by a thickening appearance on MRI. Another explanation is an ischemic or thrombotic effect related to hyperleukocytosis. The resulting hyperviscosity and subsequent disruption of hypophyseal portal capillary flow can impede release of hypothalamic hormones destined for the pituitary. Our patient had MRI findings of an abnormally thickened stalk and lack of “bright spot” which supports the hypothesis of leukemic infiltration and significant disruption of the hypothalamic-pituitary axes.

BACKGROUND AND AIMS: Evaluation for dyssynergia is the most common reason that gastroenterologists refer patients for anorectal manometry, because dyssynergia is amenable to biofeedback by physical therapists. High-definition anorectal manometry (3D-HDAM) is a promising technology to evaluate anorectal physiology, but adoption remains limited by its sheer complexity. We developed a 3D-HDAM deep learning algorithm to evaluate for dyssynergia.METHODS: Spatial-temporal data were extracted from consecutive 3D-HDAM studies performed between 2018-2020 at a tertiary institution. The technical procedure and gold standard definition of dyssynergia were based on the London consensus, adapted to the needs of 3D-HDAM technology. Three machine learning models were generated: (1) traditional machine learning informed by conventional anorectal function metrics, (2) deep learning, and(3) a hybrid approach. Diagnostic accuracy was evaluated using bootstrap sampling to calculate area-under-the-curve (AUC). To evaluate overfitting, models were validated by adding 502 simulated defecation maneuvers with diagnostic ambiguity. RESULTS: 302 3D-HDAM studies representing 1,208 simulated defecation maneuvers were included (average age 55.2 years; 80.5% women). The deep learning model had comparable diagnostic accuracy (AUC=0.