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Healthcare professionals often feel challenged by complex patients and the associated care needs during care transition. Interprofessional collaboration (IPC) is considered an effective approach in such situations. However, a fragmented healthcare system can limit IPC. This study explored experiences of Swiss healthcare professionals regarding complex patient care transition and the potential of IPC. Professionals from nursing, medicine, psychology, physiotherapy, dietetics and nutrition, social service, occupational therapy, and speech therapy were included. A qualitative between-method triangulation design was applied, with two focus group discussions and ten individual interviews. The combination of different data-collection methods allowed us to explore complex patient care transition and to systematically add perspectives of healthcare professionals from different care settings. Three main themes were identified: (1) Participants described their vision of an ideal complex patient care transition, i.e., the status they would like to see implemented; (2) participants reported challenges in complex patient care transition as experienced today; and (3) participants suggested ways to improve complex patient care transition by IPC. This study highlighted that healthcare professionals regarded IPC as an effective intervention to improve complex patient care transition. It emerged that sustainable implementation of IPC across care organizations is currently limited in Switzerland. In the absence of strong and direct promotion of IPC by the healthcare system, professionals in clinical practice can further promote IPC by finding hands-on solutions to overcome organizational boundaries.

Purpose of Review To present a clinically oriented review of selective serotonin reuptake inhibitor (SSRI)-related bleeding issues commonly addressed by consult-liaison psychiatrists. Recent Findings Concomitant medical, surgical, or hospital-based conditions exacerbate the risk of SSRI-related bleeding even though a review of the literature suggests it is only marginally elevated. Psychiatrists and other clinicians need to consider these conditions along with antidepressant benefits when answering the question: to start, hold, continue, or change the antidepressant? Summary Where an evidence base is limited, mechanistic understanding may help consult-liaison psychiatrists navigate this terrain and collaborate with other medical specialties on responsible antidepressant management. Most often, the risk is cumulative; data are not directly applicable to complex clinical situations. This review incorporates a hematologic perspective and approach to bleeding risk assessment along with extant data on SSRI-induced bleeding risk ad specific medical conditions.

Purpose of ReviewThe current review aims to provide an overview of migraine treatment strategies in medically complex patients, including those with renal, liver, and cardiovascular disease.Recent FindingsIn cardiovascular disease, gepants are likely safe for acute therapy; NSAIDs, ergotamines, and triptans are not recommended. Beta-blockers, ACEi/ARBs, and verapamil have potential cardiovascular benefits in addition to migraine preventive benefit. Frovatriptan requires no dose adjustments in kidney disease or in mild to moderate liver disease. Gepants are safe acute and preventive treatment options in mild and moderate renal and hepatic disease. TCAs and valproic acid require no dose adjustments in renal disease. OnabotulinumtoxinA is likely safe in cardiac, renal, and hepatic impairment. Although CGRP monoclonal antibodies are likely safe in renal and hepatic disease, further study is needed in these conditions as well as in cardiac disease, and no dosing recommendations are available.SummaryEffective options are available for those with complex medical comorbidities. Further research is required on the safety of newer migraine-specific therapies in these complex populations.

Introduction and ObjectivesRespiratory conditions drive significant demand for ambulance services, disproportionately affecting the most deprived communities.This study examines the impact of targeted dispatch of Specialist Paramedics and Nurses in Urgent Care (SP/NUCs) on patient conveyance rates. SP/NUCs possess enhanced skillsets facilitating care closer to home for medically complex patients, enhancing patient experience and aligned to national strategy. Outcomes were compared against those of standard double-crewed ambulances (DCA)MethodsThis exploratory retrospective study analysed data between 22/7/24 to 24/22/24 and 25/11/25 to 31/3/25 from ambulance service computer aided despatch (CAD) data. Included calls were categorised as ‘breathing difficulties’ using Advanced Medical Priority Dispatch System (AMPDS) triage.ResultsSPUC attendance is associated with increased care at home, with the mean rate across all regions at 38.4%, compared to 27.2% for DCA crews. Higher rates of care at home were associated with codes relating to ineffective breathing and unresponsiveness, difficulty speaking or visible skin perfusion changes. This suggests that SP/NUCs can support alternative care pathways, for high-acuity respiratory presentations.Regional variation persisted. The effect was most notable in two ICS areas, whilst the third showed lower care at home where SP/NUCs attended (28.6% vs. 33.7%). This divergence may reflect local differences in acuity, dispatch profiles, or the implementation of clinical pathways, underscoring the complexity of system-level influence.An estimated mean cost of £417 per conveyed patient and £287 per non-conveyed patient, produces an estimated saving of £14,255 per 1,000 SPUC- attended incidents.The comparison between two reference periods revealed a strengthening of the SP/NUC effect. In contrast, conveyance rates for DCA-attended incidents either remained stable or increased, suggesting that the observed change is linked to changes in SP/NUC clinical practice or operating environment.ConclusionsThese findings reinforce the value of SP/NUCs in providing care closer to home for patients with high acuity breathing difficulties and offers notable financial savings. The variation across regions and dispatch profiles highlights the importance of local context, including case mix, operational models, and clinical decision-making culture. Further health economic evaluation is recommended, and multivariate analysis of other factors may be necessary to inform service development.

Application for ESRA Abstract Prizes:Background and AimsErector Spinae Plane (ESP) blocks are popular for pain management due to their safety profile. While cadaveric studies indicate potential ventral injectate spread, clinically significant epidural blockade remains exceptionally rare. This report aims to describe an unusual case of extensive epidural spread following a lumbar ESP block, highlighting the potential contributing role of a vertebral compression fracture.MethodsA 73-year-old male with an LVAD and osteoporosis presented with new lower back pain from a subacute L2 vertebral compression fracture. A bilateral lumbar L2 ESP block was performed using 20 mL of 0.25% bupivacaine per side (patient weight 88 kg). Immediate post-procedure assessment revealed significant bilateral lower extremity motor paralysis and sensory loss, consistent with extensive epidural spread.ResultsThe motor and sensory blockade fully resolved within hours as the local anesthetic wore off. We hypothesize that the L2 compression fracture, combined with the patient‘s osteoporosis, chronic kidney disease, peripheral edema, and hypoalbuminemia, may have disrupted fascial planes or altered tissue permeability, creating a pathway for unintended neuraxial spread.Abstract P340 Figure 1Subacute L2 vertebral compression fracture[Image Omitted. See PDF.]ConclusionsThis case suggests that vertebral compression fractures may represent a potential risk factor for epidural spread during lumbar ESP blocks. Clinicians should exercise vigilance, conduct thorough pre-procedure assessment for spinal pathologies, and consider alternative injection levels to enhance safety, particularly in medically complex patients.

Background An ageing population leads up to increasing multi-morbidity and polypharmacy. This demands a comprehensive and interprofessional approach in meeting patients’ complex needs. This study describes graduate students’ experiences of working practice based in interprofessional teams with complex patients’ care needs in nursing homes. Method Students from advanced geriatric nursing, clinical nutrition, dentistry, medicine and pharmacy at the University of Oslo in Norway were assigned to groups to examine and develop a care plan for a nursing home patient during a course. Focus groups were used, 21 graduate students participating in four groups. Data were collected during spring 2018, were inductively analysed according to a thematic analysis method (Systematic Text Condensation). An analytical framework of co-ordination practices was applied to get an in-depth understanding of the data. Results Three themes were identified: 1) Complex patients as learning opportunities - an eye-opener for future interprofessional collaboration 2) A cobweb of relations, and 3) Structural facilitators for new collective knowledge . Graduate university students experienced interprofessional education (IPE) on complex patients in nursing homes as a comprehensive learning arena. Overall, different co-ordination practices for work organization among the students were identified. Conclusions IPE in nursing homes facilitated the students’ scope from a fragmented approach of the patients towards a relational and collaborative practice that can improve patient care and strengthen understanding of IPE. The study also demonstrated the need for preparatory teamwork training to gain maximum benefit from the experience. Something that can be organized by the education institutions in the form of a stepwise learning module and as an online pre-training course in interprofessional teamwork. Further, focusing on the need for well thought through processes of the activity by the institutions and the timing the practice component in students’ curricula. This could ensure that IPE is experienced more efficient by the students.

Concomitant direct oral anticoagulants (DOACs) and tyrosine kinase inhibitor targeting vascular endothelial growth factor receptor (anti-VEGF TKI) have been associated with a higher risk of bleeding. Nevertheless, concomitant administration seems frequent in clinical practice in patients with cancer-associated thrombosis and appears to be safe according to the retrospective study by Boileve A. et al. But the risk of an additional pharmacokinetic interaction between anti-VEGF TKI and DOACs must be considered, in case of P-glycoprotein (P-gp) inhibition by the TKI. We describe a case report with a major bleeding event in a renal metastatic cancer patient treated with cabozantinib and rivaroxaban. This case highlights the difficult therapeutic decision in a complex patient with cancer-associated thrombosis, who refused the anticoagulant subcutaneous route. Accumulation of bleeding risk factors (genito-urinary tumor localization) was additive to several pharmacodynamic interactions (acetylsalicylic acid, venlafaxine) and a potential pharmacokinetic interaction between cabozantinib and rivaroxaban. Indeed, cabozantinib-related P-glycoprotein inhibition could have led to a supratherapeutic level of rivaroxaban, contributing partly to the bleeding event. Before combining an anti-VEGF TKI and DOACs, a multidisciplinary pretherapeutic assessment seems crucial to evaluate the patient’s bleeding risk factors, pharmacodynamic interactions, and the risk of pharmacokinetic interactions mediated by P-gp.

Background: The increasing complexity of patient care demands coordinated and integrated approaches involving multiple health and social care professionals. Social capital among professionals plays a critical role in facilitating effective collaboration and continuity of care for complex patients. Objectives: This pilot study aimed to develop and test an instrument based on the position generator method to measure perceived, potential, and activated social capital for patients within professional networks involved in complex patient care in Croatia. Methods: The instrument enabled differentiation between the existence of professional connections and their actual mobilization for patient benefit. This multidimensional approach, including activation levels for patient needs, marks a key improvement over earlier measures. Results: Results indicated that while professionals possess broad networks, the activation of these networks for patient care remains limited. Accumulated work experience is positively associated with greater activation of social capital, whereas formal changes in the work environment showed no significant impact. Conclusions: Despite sample limitations restricting generalizability, the instrument demonstrated sensitivity and applicability for mapping professional networks in healthcare settings. This study lays the groundwork for further research with larger samples to validate the instrument and support the development of coordinated care systems leveraging social capital for improved outcomes in complex patient care.

Abstract Disclosure: N.M. Goldenberg: None. M. Bornovali: None. M. Spivak: None. Objective: to analysis outcomes of cortisol pump use in difficult to control Adrenally Insufficient (AI) patients. Retrospective analysis of chart of 27 difficult to control patients with different versions of AI, who were started on Cortisol pump mimicking circadian/ultracadian rhythm 3 month-8 years ago. Every patient was discussed that this therapy is not FDA approved. The potential side effects were discussed and written information was provided. The analysis was conducted in 1/2025. Results: 27 Patients, 25 are female. Average age at the start of the pump is 42 yo (11-61yo).9 (33%) patients have primary AI, 2 with non-classical CAH, 7 have pituitary, 9 (33%) tertiary AI due to overuse of steroids for other conditions. 1 is on Solu-Medrol per pump (Solu-Cortef did ont work) and the rest on Solu-Cortef. 18 (67%) patient have Hypermoblity or EDS, 7 were not tested, the rest are negative. 24 of 27 (89%) report gastrointestinal issues, including 3 with Bariatric Sx, 8 with Gluten intolerance/Celiac disease, 6 with Gastroparesis; 1 with cystic fibrosis and Exocrine pancreatic insufficiency, 1 on TPN due to MCAS. 16 (59%) with POTS, 9 (33%) with diagnosed MCAS.9 patients started before May 2020, 10 started 2022-2023, 8 started in 2024. Of 27 patients 6 patients stopped using pump (22%). They stopped it 3 month-6 years after the initiatio . Three (50%) stopped due to skin reactions. One developed severe COVID and was on high doses of injectable steroids in ICU for 3 weeks and eventually transitioned to oral Dexamethasone. One patient reported that pump was not \"working\", was eventually able to change to different steroid regimen. One deceased due to unrelated medical issues. All but 1 patients reported that use of the pump was life changing and helped people to feel better emotionally and physically. They reported having less pre-crisis situations where they have to updose the steroids and go to ER due to adrenal issues. Discussion: in medically complex patients with adrenal insufficiency when oral steroids do not help with control of the AI symptoms, use of Steroid pump is a reasonable choice, that helps people to improve their quality of life and reduces ER visits. 22% of patients did not tolerate the treatment, most of them due to local site reaction. Longer prospective studies are needed. Presentation: Saturday, July 12, 2025