State-of-the-Art Review: Use of Antimicrobials at the End of Life

Navigating antibiotics at the end of life is a challenge for infectious disease (ID) physicians who remain deeply committed to providing patient-centered care and engaging in shared decision making. ID physicians, who often see patients in both inpatient and outpatient settings and maintain continuity of care for patients with refractory or recurrent infections, are ideally situated to provide guidance that aligns with patients' goals and values. Complex communication skills, including navigating difficult emotions around end-of-life care, can be used to better direct shared decision making and assist with antibiotic stewardship.

Cathepsin C role in inflammatory gastroenterological, renal, rheumatic, and pulmonary disorders

Cathepsin C (CatC, syn. Dipeptidyl peptidase I) is a lysosomal cysteine proteinase expressed in several tissues including inflammatory cells. This enzyme is important for maintaining multiple cellular functions and for processing immune cell-derived proteases. While mutations in the CatC gene were reported in Papillon-Lefèvre syndrome, a rare autosomal recessive disorder featuring hyperkeratosis and periodontitis, evidence from clinical and preclinical studies points toward pro-inflammatory effects of CatC in various disease processes that are mainly mediated by the activation of neutrophil serine proteinases. Moreover, tumor-promoting effects were ascribed to CatC. The aim of this review is to highlight current knowledge of the CatC as a potential therapeutic target in inflammatory disorders.

Inhibition of ACAT as a Therapeutic Target for Alzheimer's Disease Is Independent of ApoE4 Lipidation

APOE4, encoding apolipoprotein E4 (apoE4), is the greatest genetic risk factor for Alzheimer's disease (AD), compared to the common APOE3. While the mechanism(s) underlying APOE4-induced AD risk remains unclear, increasing the lipidation of apoE4 is an important therapeutic target as apoE4-lipoproteins are poorly lipidated compared to apoE3-lipoproteins. ACAT (acyl-CoA: cholesterol-acyltransferase) catalyzes the formation of intracellular cholesteryl-ester droplets, reducing the intracellular free cholesterol (FC) pool. Thus, inhibiting ACAT increases the FC pool and facilitates lipid secretion to extracellular apoE-containing lipoproteins. Previous studies using commercial ACAT inhibitors, including avasimibe (AVAS), as well as ACAT-knock out (KO) mice, exhibit reduced AD-like pathology and amyloid precursor protein (APP) processing in familial AD (FAD)-transgenic (Tg) mice. However, the effects of AVAS with human apoE4 remain unknown. In vitro, AVAS induced apoE efflux at concentrations of AVAS measured in the brains of treated mice. AVAS treatment of male E4FAD-Tg mice (5xFAD+/-APOE4+/+) at 6-8 months had no effect on plasma cholesterol levels or distribution, the original mechanism for AVAS treatment of CVD. In the CNS, AVAS reduced intracellular lipid droplets, indirectly demonstrating target engagement. Surrogate efficacy was demonstrated by an increase in Morris water maze measures of memory and postsynaptic protein levels. Amyloid-beta peptide (Aβ) solubility/deposition and neuroinflammation were reduced, critical components of APOE4-modulated pathology. However, there was no increase in apoE4 levels or apoE4 lipidation, while amyloidogenic and non-amyloidogenic processing of APP were significantly reduced. This suggests that the AVAS-induced reduction in Aβ via reduced APP processing was sufficient to reduce AD pathology, as apoE4-lipoproteins remained poorly lipidated.

Mental health trends among medical students

Student mental health concerns can manifest in several forms. Medical students juggling a multitude of trials (i.e., intense academic rigor, financial debt, sleep deprivation, lack of control, continual exposure to sickness and death, and training mistreatment) can help explain the higher prevalence of psychological disorders within this population. Furthermore, these mental health difficulties are not static; certain challenges move into the forefront as students face key transition points in schooling. Primary examples include the entry year of medical school, the shift from preclinical curriculum to clinical training, and the final moments prior to beginning residency. Given the existing mental health trends among medical students at baseline, it can be concluded that the COVID-19 pandemic has exacerbated the stress, anxiety, and depression associated with medical education. Solutions do indeed exist to address the moral injury medical students face, from expanded crisis management training and implementation of peer support networks to destigmatization of and improved access to professional mental health resources. It is up to the curators of the medical education system to make these solutions the new status quo.

Phenobarbital for the Management of Alcohol Withdrawal Syndrome in Critically Ill, Surgical-Trauma Patients

INTRODUCTION

While benzodiazepines (BZD) are the standard of care therapy for the management alcohol withdrawal syndrome (AWS), phenobarbital (PHB) is often used as an alternative agent. The objective of this study is to assess the use of PHB therapy for the management of AWS in trauma-surgical intensive care unit (TSCU) patients.

MATERIALS AND METHODS

This is an institutional review board-approved single-center, retrospective study conducted at a large academic medical center. Patients aged ≥ 18 y admitted to the TSCU receiving PHB therapy for primary management of AWS were included. The primary outcome evaluated was the incidence of AWS-related complications (AWSRC) defined as severe agitation, delirium tremens, or seizures following initiation of PHB. Secondary outcomes included the incidence of oversedation and duration of mechanical ventilation.

RESULTS

Sixty patients were included in this study. AWSRC following initiation of PHB occurred in 65% of patients. Median time to initiation of PHB (42 versus 18 h, P = 0.001) and rates of oversedation (79.5% versus 28.6%, P < 0.001) were significantly greater among patients who experienced AWSRC compared to those who did not. Univariate analysis revealed use of BZD therapy for ≥ 24 h prior to PHB initiation, time from hospital admission to PHB initiation ≥ 24 h, presence of AWS symptoms at baseline, and baseline MINDS score > 6 were risk factors for AWSRC.

CONCLUSIONS

Delays in initiation of PHB appear to be associated with an increased risk for developing AWSRC. Further research is needed to identify an optimal dosing strategy for TSCU patients at high risk for severe AWS.

Does point-of-care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHOC-ED investigators

PURPOSE

Point-of-care ultrasonography (POCUS) is an established tool in the management of hypotensive patients in the emergency department (ED). We compared the diagnostic accuracy of a POCUS protocol versus standard assessment without POCUS in patients with undifferentiated hypotension.

METHODS

This was an international, multicenter randomized controlled trial included three EDs in North America and three in South Africa from September 2012 to December 2016. Hypotensive patients were randomized to early POCUS protocol plus standard care (POCUS group) or standard care without POCUS (control group). Initial and secondary diagnoses were recorded at 0 and 60 min. The main outcome was measures of diagnostic accuracy of a POCUS protocol in differentiating between cardiogenic and non-cardiogenic shock. Secondary outcomes were diagnostic performance for shock sub-types, as well as changes in perceived category of shock and overall diagnosis.

RESULTS

Follow-up was completed for 270 of 273 patients. For cardiogenic shock, the POCUS-based diagnostic approach (POCUS) performed similarly to the non-POCUS approach (control) for specificity [95.5% (89.9-98.5) vs.93.8% (87.7-97.5)]; positive likelihood ratio (17.92 vs 14.80); negative likelihood ratio (0.21 vs 0.09) and diagnostic odds ratio (85.6 vs 166.57), with a similar overall diagnostic accuracy between the two approaches [93.7% (88-97.2) vs 93.6% (87.8-97.2)]. Diagnostic performance measures were similar across sub-categories of shock.

CONCLUSION

This is the first randomized controlled trial to compare diagnostic performance of a POCUS protocol to standard care without POCUS in undifferentiated hypotensive ED patients. POCUS performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test; however, performance did not differ meaningfully from standard assessment.

Epoxy lining influence on recycled water quality during pipeline transit for potable reuse

An epoxy treatment was applied to a pipeline used to convey advanced treated recycled water from a purification facility to a recharge site. The epoxy treatment was applied to prevent further deterioration (corrosion) of the interior cement mortar lining (CML). A soil column study was conducted to evaluate the effect of the epoxy liner on the clogging potential of water before and after conveyance. The clogging potential was represented by differences in the column's relative hydraulic conductivity and water quality, between the treatment plant and injection site, before and after epoxy lining. Hydraulic conductivity of columns at the injection well site declined rapidly before epoxy and improved considerably after epoxy application. Total suspended solids (TSS) and cellular adenosine triphosphate (cATP) median concentrations improved significantly. Before epoxy, TSS increased with pipeline transit from 0.005 to 0.053 (mg/L) compared with 0.009 mg/L after epoxy. Before epoxy, cATP increased from 0.14 to 1.6 pg/ml across pipeline transit compared with 0.37 pg/ml after epoxy. Aluminum and nitrate followed similar trends. Results indicate that epoxy liner reduced the clogging potential of high purity recycled water, likely due to a decrease in particle and biomass load (clogging constituents) accumulated during pipeline transit. PRACTITIONER POINTS: Clogging potential of advanced treated recycled water increases with pipeline transit. Epoxy lining the pipeline used for conveyance reduces the particulate and microbial loading of the highly purified water. Applying epoxy to pipelines used to convey advanced treated recycled water has the dual benefit of infrastructure protection and improving water quality. Reducing particle and microbial load in the advanced treated recycled water can reduce maintenance frequencies and elongate production periods for MAR applications.

PI3K/mTOR inhibitor omipalisib prolongs cardiac repolarization along with a mild proarrhythmic outcome in the AV block dog model

Background

The phosphoinositide 3-kinase (PI3K) signaling pathway is an interesting target in cancer treatment. The awareness of the proarrhythmic risk of PI3K inhibitors was raised because PI3K is also involved in regulating signaling toward cardiac ion channels. Canine cardiomyocytes treated with PI3K inhibitors show an increased action potential duration and reduced cardiac repolarizing currents. Now, the potential proarrhythmic effect of chronic treatment of PI3K/mTOR inhibitor GSK2126458 (omipalisib) was investigated in the atrioventricular (AV) block dog model.

Methods

Purpose-bred Mongrel dogs received complete AV block by ablation of the bundle of His and their hearts were paced in the right ventricular apex at VDD-mode (RVA-VDD). In this way, sinus rhythm was maintained for 15 ± 1 days and thereby bradycardia-induced cardiac remodeling was prevented. Dogs received 1 mg/kg omipalisib once (n = 3) or twice (n = 10) a day via oral administration for 7 days. Under standardized conditions (anesthesia, bradycardia at 60 beats/min, and a dofetilide challenge), potential proarrhythmic effects of omipalisib were investigated.

Results

Twice daily dosing of omipalisib increased accumulative plasma levels compared to once daily dosing accompanied with adverse events. Omipalisib prolonged the QT interval at baseline and more strongly after the dofetilide challenge (490 ± 37 to 607 ± 48 ms). The arrhythmic outcome after omipalisib resulted in single ectopic beats in 30% of dogs perpetuating in multiple ectopic beats and TdP arrhythmia in 20% of dogs. Isolated ventricular cardiomyocytes from omipalisib-treated dogs showed a diminished I_Ks current density.

Conclusion

Chronic treatment of PI3K/mTOR inhibitor omipalisib prolonged the QT interval in a preclinical model under standardized proarrhythmic conditions. Furthermore, this study showed that electrical remodeling induced by omipalisib had a mild proarrhythmic outcome.

Yakima County Incidence Rates of Sexually Transmitted Infections From 2013 to 2018 in Urban-Rural and Area-Deprivation Continua

BACKGROUND

This study aimed to examine variations in the incidence rates of sexually transmitted infections (STIs; i.e., chlamydia, gonorrhea, and syphilis) across the urban-rural and area-deprivation continua from January of 2013 to December of 2018 in Yakima County, Washington. The rates of STIs has been increasing in the United States in the past decade. Historically, Yakima County has higher rates of STIs than state and national rates. In addition, Yakima County contains rural areas and areas with greater deprivation that face gaps in access to care.

METHODS

The Washington State Department of Health Database Surveillance System was used to conduct the study. The data set included diagnosed cases of chlamydia, gonorrhea, and syphilis with positive laboratory test results for the duration of the study period. Incidence rates of STIs were calculated and statistically analyzed across the urban-rural and area-deprivation continua using rural-urban commuting area codes and the area deprivation index.

RESULTS

The incidence rates of STIs increased from January of 2013 to December of 2018. Rates of STI did not differ in micropolitan, small town, and rural block groups compared with the metropolitan block groups. Most-deprived block groups had significantly higher STI rates compared with less deprived block groups.

CONCLUSIONS

There is a need for increased STI intervention in higher deprivation areas including STI education. Public health officials and health care providers should be aware of these risk factors and tailor interventions to the neighborhood they serve.

P-750 The cost-effectiveness of transvaginal hydrolaparoscopy versus hysterosalpingography in the work-up for subfertility

Study question

Is transvaginal hydrolaparoscopy (THL) cost-effective compared to hysterosalpingography (HSG) in the work-up for subfertility in a population at low-risk for tubal pathology?

Summary answer

THL is cost-effective compared to HSG in a preselected group of women at low-risk of tubal pathology.

What is known already

Tubal pathology is a common cause of subfertility and tubal patency testing plays an important part in the work-up of the subfertile couple and the subsequent counseling for fertility treatment. THL is an out-patient procedure. After access through the pouch of Douglas, the tubes and pelvic cavity are directly observed using hydroflotation, whereas HSG is a radiographic evaluation of the uterine cavity and patency of the tubes with injection of contrast medium in the uterine cavity. Both methods are safe and feasible for subfertile women at low-risk of tubal pathology.

Study design, size, duration

We performed an economic analysis as part of a randomized controlled trial comparing THL and HSG in the work-up for subfertility. Women were eligible if they had an indication for evaluation of tubal patency. Primary outcome was a conception leading to live birth in 24 months. We randomly assigned 300 subfertile women to THL or HSG between May 2013 and October 2016.

Participants/materials, setting, methods

This study was performed in four Dutch teaching hospitals. The economic evaluation was performed from a health care perspective. Costs were either derived from literature or calculated. The mean costs and outcomes for each treatment group were compared. Costs were combined with effectiveness by calculating ICER, and bootstrap resampling was performed. We generated a cost-effectiveness plane and cost-effectiveness acceptability curves.

Main results and the role of chance

After 24 months of follow-up there was a 3% difference in live birth rate in favour of the THL group (58.5% in the THL group versus 55.4% in the HSG group (83/142 versus 82/148 difference 3.0% (95% CI: -8.3 – 14.4)). Multiple pregnancy and miscarriage rate were low and did not differ between groups. Ectopic pregnancy occurred in two women in the HSG group and not in the THL group. The mean cost was lower in the THL group, compared to the HSG group (THL group 4,927 EUR versus 5,197 EUR in the HSG group, difference -270 EUR). Although the costs of the diagnostic procedure itself were higher in the THL group (425 EUR versus 289 EUR, difference 136 EUR), the costs for fertility treatments are higher in the HSG group. The base case outcome is that THL costs less and is more effective than HSG, making THL the dominant strategy. The spread of the bootstrap indicates that there is uncertainty regarding the effectiveness of THL over HSG but less uncertainty regarding the cost difference between THL and HSG.

Limitations, reasons for caution

This trial was conducted in the Netherlands, using price calculations of the Dutch healthcare system in Euro’s. Since prices of fertility treatments and especially ART or fertility enhancing surgery can vary widely worldwide, it is possible that the outcomes of our study are not generalizable to other countries.

Wider implications of the findings

The findings of our trial suggest that in a preselected group of women with low risk for tubal pathology, a diagnostic strategy starting with THL is cost-effective compared to a diagnostic strategy starting with HSG in the workup for subfertility.

Trial registration number

NTR3462

TNNI3K delays atrioventricular conduction and reduces connexin-45 gap junctional coupling

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Dutch Research Council (NWO Talent Scheme)

Introduction

Cardiac conduction delay is the main substrate for triggering arrhythmias. Hence, prolongation of the PR interval on the electrocardiogram (ECG) is a strong predictor of atrial fibrillation, the most common cardiac arrhythmia. In previous research, cardiac troponin I-interacting kinase (TNNI3K) has been identified as a regulator of the PR interval. Various inbred mouse strains showed a correlation between Tnni3k expression levels and PR interval durations. Additionally, transgenic mice overexpressing hTNNI3K presented an extreme PR interval prolongation.

Objective

This study aims to unravel the mechanism underlying TNNI3K-driven PR interval prolongation.

Methods

ECG parameters were recorded in mice expressing physiological levels of Tnni3k (congenic), overexpressing hTNNI3K (TNNI3Ktg), or overexpressing kinase-dead hTNNI3K (TNNI3K-KDtg) and were compared to low-Tnni3k expressing DBA/2J control mice. Atrioventricular (AV) conduction was measured in Langendorff-perfused isolated hearts by electrical mapping. Cellular electrophysiology and conductance were measured using the (dual) patch-clamp technique. AV nodal collagen levels were identified by Pico Sirius Red staining. Candidate interactors were identified by immunoprecipitation of transfected HEK293A cell lysates. In stable HeLa-Connexin 45 (Cx45) cell lines expressing TNNI3K, Cx45 protein expression and phosphorylation levels were investigated by Western blot. Localisation of Cx45 was characterised by immunofluorescence.

Results

At six weeks of age, congenic and TNNI3Ktg mice show a 17% and 35% prolonged PR interval duration, respectively. Nonetheless, the PR interval of TNNI3K-KDtg mice did not change. Electrical mapping experiments on TNNI3Ktg mouse hearts show a corresponding AV conduction delay, which was neither driven by changes in cellular atrial cardiomyocyte electrophysiology nor driven by AV-nodal fibrosis. We next identified Cx45, a highly expressed connexin in the AV node, as a potential TNNI3K interactor. HeLa-Cx45 cells expressing TNNI3K demonstrated a reduced Cx45 conductance compared to controls without changes in kinetics. Moreover, we observed relatively decreased Cx45 phosphorylation and increased Cx45 intracellular accumulation.

Conclusion

We here present TNNI3K as a kinase-driven modulator of PR interval prolongation and AV conduction delay, which is independent of atrial electrophysiology and AV nodal fibrosis. We further identified Cx45 as a novel interactor of TNNI3K. The presence of TNNI3K reduces Cx45 gap junctional conductance and promotes intracellular Cx45 protein accumulation, which could explain the PR interval prolongation in vivo. Altogether, this study implies a crucial role for TNNI3K in AV nodal conduction.

Patient satisfaction and adverse effects following the use of topical hair fiber fillers

Introduction:

Alopecia (hair loss) commonly affects patients and can severely affect one's confidence and self-esteem. In addition to medical therapy, hair filler fibers can improve the gross appearance of thinning hair in a targeted manner by making hair appear fuller and thicker. The objective of this study is to assess patient use, satisfaction, and adverse effects following the application of a commercially available hair fiber filler product.

Materials and Methods:

This cross-sectional study was conducted at an academic tertiary dermatology center. Alopecia patients were supplied a keratin hair fiber filler, which best matched their natural hair color. Following 90 days of application, patients were asked to complete questionnaires to assess patient satisfaction and record patient-reported adverse events.

Results:

Twenty women and 20 men with hair loss participated. Patients reported improved hair volume and increased perceptions of confidence and attractiveness after applying fiber. Most subjects (92.5%) reported a high level of satisfaction with the fiber's ability to match hair color and provide sufficient coverage. No serious adverse effects were reported.

Conclusion:

Alopecia has a negative impact on quality of life and several psychological domains. Topical hair filler fiber can serve as an effective and safe camouflage for patients with alopecia with high user satisfaction.

243. Analysis of Risk Factors Associated with Adverse Outcomes Following Calcium Sulfate Bead Use in Periprosthetic Joint Infections

Background

Calcium sulfate (CS) beads are increasingly utilized in orthopedic surgeries as a delivery vehicle to administer local antimicrobials intraoperatively. Hypercalcemia, AKI, and elevated serum antimicrobial levels have been reported as potential complications, especially with higher bead volumes. We analyzed the risk factors associated with adverse outcomes among patients with PJIs who received intraoperative CS beads loaded with tobramycin and vancomycin.

Methods

We conducted a retrospective review of adult patients with PJIs who received CS beads from October 2019 to October 2020. Primary outcomes included the incidence of AKI (defined using RIFLE criteria) and hypercalcemia (≥ 11 mg/dL). Logistic regression with forward entry selection of independent variables based on a liberal probability significance of α < 0.25 was used to model the relationships between our variables. Independent variables with clinical relevance that did not meet the conditional selection were also included in the model.

Results

A total of 171 adult patients were included for the analysis. Postoperative AKI occurred in 42 patients (24.6%) who received a mean bead volume of 32 cc. Hypercalcemia occurred in 16 patients (9.4%) who had a mean bead volume of 40 cc. In a univariate analysis, the odds of having AKI and hypercalcemia increased significantly per 10 cc of bead volume with ORs of 1.39 (95%CI, 1.06, 1.82) and 1.65 (95%CI, 1.20, 2.29), respectively. In a multivariate analysis, significant predictors of AKI included: increased bead volume (aOR 1.52; 95%CI, 1.10-2.10), female sex (aOR 2.77; 95%CI, 1.00-7.71), CHF (aOR 3.48; 95%CI, 1.08-11.28), and CAD (aOR 3.90; 95%CI, 1.25-12.18). In the adjusted model, serum tobramycin levels increased (OR 2.67; 95%CI, 1.83-3.90), calcium levels increased with a mean of 0.2 mg/dL (95%CI, 0.12, 0.28), and GFR decreased with a mean of 5.6% (95%CI, 2.8, 8.7) per 10 cc bead volume. In a subset analysis, individuals more likely to experience AKI were patients aged 65 and older (OR 1.9; P=0.039) and had CAD (OR 15.26; P=0.028).

Conclusion

Higher volume of CS beads loaded with vancomycin and tobramycin is associated with adverse outcomes. Older patients with heart disease may be at higher risk for adverse outcomes.

Disclosures

All Authors: No reported disclosures

67. Agreement Among Bayesian Dosing Software for Calculating Vancomycin Area Under the Curve

This abstract has been withdrawn.

Safety of Valganciclovir 450 mg 3 Times Weekly for Cytomegalovirus Prophylaxis in Solid Organ Transplant Recipients Requiring Hemodialysis

Background

Valganciclovir is the most commonly used antiviral for cytomegalovirus (CMV) prophylaxis in solid organ transplant recipients. However, there are limited clinical outcomes-supported data available to guide valganciclovir dosing in patients on hemodialysis (HD). This study aimed to assess the safety of our institution's current dosing strategy of valganciclovir 450 mg 3 times weekly post-HD.

Methods

This was a single-center retrospective review of all adult nonkidney transplant recipients between May 2016 and June 2018. Patients with end-stage renal disease requiring HD for >28 days posttransplant receiving valganciclovir 450 mg 3 times weekly post-HD were matched with non-HD patients receiving valganciclovir prophylaxis dosed per renal function. The primary endpoints were incidence of leukopenia, neutropenia, and thrombocytopenia while on valganciclovir prophylaxis.

Results

A total of 465 nonkidney transplants were performed during the study period, with 37 patients included in the HD group who were matched to 111 control patients in the non-HD group. Liver transplant recipients comprised 84% and 72% of each group, with none being CMV D+/R-. The rates of leukopenia (51.4% vs 51.4%, P = 1.00), severe neutropenia (absolute neutrophil count <500 cells/µL, 15.8% vs 14.0%, P = .85), and thrombocytopenia (24.3% vs 20.7%, P = .64) were similar in both HD and non-HD groups. There were no cases of CMV infection while on valganciclovir prophylaxis in either group.

Conclusions

Valganciclovir 450 mg 3 times weekly was found to have similar rates of leukopenia, neutropenia, thrombocytopenia, and CMV infection in comparison to valganciclovir dosed per renal function in non-HD transplant recipients.

Outcomes in Hospitalization in Patients with Heart Failure Undergoing Remote Pulmonary Artery Pressure Monitoring: A Systematic Review and Meta-Analysis of Major Trials

Heart failure is a leading global pandemic and a cause of economic burden. Although, treatments exist to help symptomatic alleviation, patient compliance and monitoring is the basis of ensuring efficacy. With devices that allow for remote wireless PA pressure monitoring such as CardioMEMS, the inconsistency in patient reporting and factors such as symptoms and hospitalizations can be reduced. A systematic review and meta-analysis utilizing the MEDLINE, Cochrane, and Scopus database was performed to identify randomized and non-randomized clinical trials evaluating baseline characteristics and hospitalizations. Five trials for the systematic review and 2 trials for the meta-analysis meeting the inclusion and exclusion criteria were included. Baseline characteristics included an average age of 64.6 years, male predominance, mean BMI of 29.6, predominance of HFrEF, hypertension the most prevalent comorbidity, and a mean PA pressure of 27.2 mm Hg. The follow-up periods ranged from 90 days to 12 months. There was a total of 64 adverse events, mostly non-serious. Patients who underwent remote PA monitoring were less likely to be hospitalized compared with patients who did not (Odds Ratio: 0.52; 95% Confidence Interval 0.39, 0.69). Remote PA pressure monitoring allows for reduced hospitalizations. With the recent and now resurging SARS-CoV-2 pandemic, devices such as CardioMEMS can allow for heart failure patients to be managed from home to not only reduce hospitalizations but for symptom prevention and management.

A technique for eyelid margin repair without use of marginal sutures

Purpose: To describe and evaluate a novel technique for eyelid margin repair without the use of marginal sutures.Methods: A retrospective chart review of patients who underwent primary repair of full-thickness lid margin defects using the described technique between March 2013 and May 2019 was performed. Clinical data such as indication for repair as well as size of defect was analyzed. The primary outcome measures included presence or absence of lid notching and post-operative complications such as wound dehiscence, infection, eyelid malposition, and keratopathy. Descriptive statistics were used.Results: A total of 31 cases were identified. Five were excluded in post-operative analysis for follow-up of less than 2 weeks. The average age was 59.6 years (range 22-88) and 54.8% of patients were female. Average follow up in post-operative analysis group was 17.0 weeks (range 2 weeks to 42 months). Average defect size was 5.77 mm (range 2-12 mm). Reasons for repair were resection of eyelid lesion in 25/31 (80.6%), floppy eyelid in 4/31 (12.9%), trauma in 1/31 (3.2%), and trichiasis in 1/31 (3.2%). Post-operative eyelid notching was noted in 2/26 patients (7.7%), and there were no instances of wound dehiscence, infection, eyelid malposition, or keratopathy noted.Conclusions: Our technique for full-thickness eyelid margin repair without the use of marginal sutures successfully repairs defects up to 12 mm for various indications. We observed comparable cosmetic outcomes to previously described techniques as well as a low rate of complications using our technique.

A sustained type I IFN-neutrophil-IL-18 axis drives pathology during mucosal viral infection

Neutrophil responses against pathogens must be balanced between protection and immunopathology. Factors that determine these outcomes are not well-understood. In a mouse model of genital herpes simplex virus-2 (HSV-2) infection, which results in severe genital inflammation, antibody-mediated neutrophil depletion reduced disease. Comparative single-cell RNA-sequencing analysis of vaginal cells against a model of genital HSV-1 infection, which results in mild inflammation, demonstrated sustained expression of interferon-stimulated genes (ISGs) only after HSV-2 infection primarily within the neutrophil population. Both therapeutic blockade of IFNα/β receptor 1 (IFNAR1) and genetic deletion of IFNAR1 in neutrophils concomitantly decreased HSV-2 genital disease severity and vaginal IL-18 levels. Therapeutic neutralization of IL-18 also diminished genital inflammation, indicating an important role for this cytokine in promoting neutrophil-dependent immunopathology. Our study reveals that sustained type I interferon (IFN) signaling is a driver of pathogenic neutrophil responses and identifies IL-18 as a novel component of disease during genital HSV-2 infection.

1705. Treatment of Disseminated Adenovirus with Cidofovir in a Patient with HIV and ESRD

Background

Adenovirus is a common cause of upper respiratory infections and gastroenteritis. Severe adenovirus infections and disseminated disease are known to occur in immunocompromised hosts. Cidofovir has been associated with clinical improvement in patients with severe or disseminated disease in which immunosuppression cannot be readily reversed or those unresponsive to supportive care. However, a narrow therapeutic index has limited its clinical use particularly in patients with end-stage renal disease (ESRD).

Methods

We present a case of disseminated adenovirus in a well-controlled person living with HIV (PLWHIV) treated successfully with dose-reduced cidofovir in the setting of ESRD on hemodialysis (HD) at the University of California Los Angeles. A literature review was conducted to investigate the treatment of severe adenovirus disease and use of cidofovir in patients with ESRD.

Results

Our patient is a 59 year-old woman who presented with fever, non-productive cough, and diarrhea. She is living with HIV/AIDS with virologic control and CD4 count of 470 treated with dose adjusted lamivudine, tenofovir alafenamide, and dolutegravir in the setting of ESRD on HD, chronic hepatitis B, and group I pulmonary hypertension. Her course was complicated by development of multifocal pneumonia with hypoxemic respiratory failure requiring high-flow nasal cannula. Adenovirus PCR was detected in stool, respiratory, and serum samples. Given high risk intubation, dose-reduced cidofovir 0.5 mg/kg weekly was given twice over three weeks with symptomatic improvement, elimination of serum adenovirus DNA, and without development of adverse medication-related effects.

Sixteen primary and review articles were identified discussing adenovirus pathology and treatment. A single pharmacokinetic study outlined a dosing regimen for cidofovir of 0.5 mg/kg weekly which provided comparable serum drug levels in asymptomatic patients with ESRD on HD compared to controls with adequate renal function.

Conclusion

This case report illustrates although there is limited data to establish the efficacy and safety of cidofovir for treatment of disseminated adenovirus infections in ESRD patients, dose-reduced cidofovir 0.5 mg/kg weekly while on HD appears to have been effective and well tolerated.

Disclosures

All Authors: No reported disclosures

Combination Therapy Using Radiofrequency Microneedling and Corticosteroids for Hypertrophic Scars: A Case Report

Dysregulated scar formation can cause hypertrophic scarring, a difficult entity to treat. Although fractionated lasers are a popular therapy for hypertrophic scars, laser-induced epidermal damage might cause pigmentary changes in individuals with darker skin tones. Radiofrequency microneedling delivers ablative energy directly to the dermis and is safe for use in such patients. We present a case of hypertrophic scarring in a patient with Fitzpatrick Skin Type IV treated with a combination of radiofrequency microneedling, topical and intralesional corticosteroids, and intralesional onabotulinumtoxinA. Three weeks posttreatment, scars were significantly improved in both color and texture. The patient did not report any side effects. Based on these results, this novel combination therapy appears to be a promising treatment modality for hypertrophic scars in patients with Fitzpatrick Skin Types IV to VI. However, further large-scale studies will need to be completed to determine long-term efficacy and possible adverse events.

Neutrophil Elastase Facilitates Tumor Cell Intravasation and Early Metastatic Events

Functional roles of neutrophil elastase (NE) have not been examined in distinct steps of the metastatic cascade. NE, delivered to primary tumors as a purified enzyme or within intact neutrophils or neutrophil granule content, enhanced human tumor cell intravasation and subsequent dissemination via NE-mediated formation of dilated intratumoral vasculature. These effects depended on picomole range of NE activity, sensitive to its natural inhibitor, α1PI. In Elane-negative mice, the lack of NE decreased lung retention of human tumor cells in experimental metastasis. Furthermore, NE was essential for spontaneous metastasis of murine carcinoma cells in a syngeneic orthotopic model of oral cancer. NE also induced tumor cell survival and migration via Src/PI3K-dependent activation of Akt signaling, vital for tumor cell dissemination in vivo. Together, our findings implicate NE, a potent host enzyme specific for first-responding innate immune cells, as directly involved in early metastatic events and a potential target for therapeutic intervention.

•

NE enhances human carcinoma cell intravasation and spontaneous metastasis

•

NE mediates formation of dilated intratumoral vasculature supporting cell intravasation

•

NE-KO mice exhibit decreased lung retention and spontaneous metastasis of tumor cells

•

NE induces tumor cell survival and migration via activation of Src/PI3K/Akt pathway

The Impact of Color Fidelity on Evaluation of Patients in the Outpatient Dermatologic Setting

BACKGROUND AND OBJECTIVES

To demonstrate that high color fidelity light-emitting diode (LED) sources are preferred by dermatologists for the evaluation of patients during standard-of-care, outpatient visits when compared to low color fidelity LED sources similar to fluorescent lighting.

STUDY DESIGN/MATERIALS AND METHODS

Three different LED sources were installed in exam rooms at a single, academic, medical institution (low color fidelity [82 color rendering index (CRI)] similar to fluorescent lighting, and high color fidelity [97 CRI and 96+red CRI]). A cross-sectional survey study was conducted in three parts. Naturalness (i.e. ability to reproduce natural, daylight conditions), effectiveness, color contrast, comfort, and overall performance of each LED source were rated on a 5-point scale from 0 to 4 with 0 being the worse, and 4 being the best. The first part included a survey of board-certified dermatologists (n = 3) assessing their visual experience while clinically evaluating a subset of patients during standard-of-care outpatient visits. The second survey was completed by dermatologic medical providers (n = 55) at three separate monthly departmental Grand Rounds sessions in which standardized patients were evaluated with the LED sources. Lastly, patients (n = 75) finished a survey assessing the comfort level of the LED sources.

RESULTS

In the first part of the study, all dermatologists significantly preferred the high color fidelity sources over low color fidelity sources based on all five evaluation criteria, with two preferring the 97 CRI LED source overall, while the third dermatologist favored 96+red CRI. Assessments provided by the 55 participants at Grand Rounds demonstrated that the 97 CRI was most "liked." Patients also preferred the high color fidelity LED source, reporting the 96+red CRI source was the "most comfortable."

CONCLUSION

Dermatologists, dermatologists-in-training and mid-level providers significantly prefer high color fidelity LED sources for outpatient evaluation of dermatologist patients in enclosed spaces, rating them the more natural, effective, comfortable, and providing superior color contrast than low color sources. Patients also favor high color fidelity LED sources as being the most comfortable in the clinic room. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Altered auto-phosphorylation of novel TNNI3K variants associated with AV-nodal re-entry tachycardia and conduction disease

Background

In the past decade, we and others have reported three families with rare genetic variants in TNNI3K, encoding the cardiac-specific troponin-I interacting kinase (TNNI3K), co-segregating with a mixed, but highly penetrant, cardiac phenotype that features predominant atrial/junctional tachycardia occurring in combination with cardiac conduction disease and dilated cardiomyopathy. We demonstrated that while the p.Thr539Ala and p.Gly526Asp TNNI3K variants had decreased auto-phosphorylation activity the p.Glu768Lys variant, present in 3 independent families, leads to increased auto-phosphorylation levels, in line with the finding that increased levels of Tnni3k expression are associated with slower atrial-ventricular conduction in mice.

Objective

Identifying new genetic variants in the TNNI3K gene associated with cardiac disease and assessing their impact on TNNI3K auto-phosphorylation levels.

Methods

Through next generation sequencing of a panel of genes associated with cardiac disease we assessed TNNI3K in patients with cardiac arrhythmias and cardiomyopathies. All variants identified were assessed in vitro for effects on auto-phosphorylation. Briefly, wild-type and mutant TNNI3K constructs were transfected into HEK293 cells, protein was extracted after 48 hours and analyzed with anti-flag and anti-phospho-tyrosine antibodies on Western blot.

Results

We identified 7 novel and rare variants in TNNI3K in 11 additional probands, with predominantly cardiac conduction disease, with or without dilated cardiomyopathy, and atrial-ventricular-re-entry-tachycardia (AVNRT). Of these, multiple variants were found to have aberrant auto-phosphorylation including almost absent auto-phosphorylation capacity for one (TNNI3K-p.Val510Leu). All three-independent wild type TNNI3K transfected HEK293 cell lysates showed similar phosphorylated TNNI3K levels and the kinase-dead negative control demonstrated no phosphorylation activity.

Conclusion

We here present 7 novel genetic variants in TNNI3K in patients with a remarkable overlap in cardiac phenotype consisting mainly of AVNRT and cardiac conduction disease. We further show that some of these variants alter the auto-phosphorylation of TNNI3K. These results indicate a more prevalent role of variants in TNNI3K in human cardiac disease and a possible in vitro functional assay to assess the pathogenicity of such variants.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Dutch Research Council (NWO Talent Scheme VIDI-91718361)

Distributed Temperature Sensing to Measure Infiltration Rates Across a Groundwater Recharge Basin

Managed aquifer recharge is used to augment groundwater resources and provide resiliency to water supplies threatened by prolonged droughts. It is important that recharge facilities operate at their maximum efficiency to increase the volume of water stored for future use. In this study, we evaluate the use of distributed temperature sensing (DTS) technology as a tool to measure high-resolution infiltration rates at a large-scale recharge facility. Fiber optic cable was laid out inside a spreading basin in a spiral pattern, at two different depths. The cables measured the propagation of diurnal surface water temperature oscillations into the basin depth. The rate of heat propagation is proportional to the velocity of the water, making it possible to estimate the infiltration rate from the temperature measurements. Our results showed that the infiltration rate calculated from DTS, averaged over the entire basin, was within 5% of the infiltration rate calculated using a conventional metering method. The high-resolution data obtained from DTS, both spatially and temporally, revealed heterogeneous infiltration rates throughout the basin; furthermore, tracking the evolution of infiltration rates over time revealed regions with consistently high infiltration rates, regions with consistently low infiltration rates, and regions that evolved from high to low rates, which suggested clogging within that region. Water utilities can take advantage of the high-resolution information obtained from DTS to better manage recharge basins and make decisions about cleaning schedule, frequency, and extent, leading to improved basin management strategies, reduced O&M costs, and increased groundwater recharge.

Comparative effectiveness of antiretroviral drug classes for the treatment of HIV infection in patients with high viral loads: a multicentre retrospective cohort study

OBJECTIVES

We aimed to compare the effectiveness of antiretroviral therapy (ART) classes for achieving HIV RNA suppression to < 50 HIV-1 RNA copies/mL within 6 months of initiation with high viral loads (VLs). Secondary objectives were to compare viral suppression (VS) at 12 weeks and 12 months, partial HIV RNA suppression to < 200 copies/mL, time to VS, time to rebound, and change in CD4 cell count.

METHODS

This was a multicentre, retrospective, observational study. Adult patients were included if they initiated ART between January 2005 and December 2016 with a VL ≥ 100 000 copies/mL.

RESULTS

There were 220 patients included in the study. The median VL was 252 919 [interquartile range (IQR) 149 472-500 000] copies/mL. Nonnucleoside reverse transcriptase inhibitor (NNRTI) recipients were more likely to achieve VS by 6 months compared to those initiating ART containing protease inhibitors (PIs) [75.4% vs. 44.1%, respectively; odds ratio (OR) 3.34; 95% confidence interval (CI) 1.62-6.90] or integrase strand transfer inhibitors (INSTIs) (75.4% vs. 55.8%, respectively; OR 2.40; 95% CI 1.03-5.58). VS at 12 weeks was more frequent with INSTI-containing regimens than with PIs (28.9% vs. 9.0%, respectively; OR 4.10; 95% CI 1.69-9.92). VS at 12 months did not significantly differ between treatment regimens. Median time to complete VS for INSTI, PI and NNRTI recipients was 22.3 (95% CI 13.4-33), 30.1 (95% CI 25-36) and 19.9 (95% CI 16-22.3) weeks, respectively. There were no significant differences in time to viral rebound or change in CD4 cell counts.

CONCLUSIONS

Patients with high VLs initiated on NNRTIs were more likely to achieve VS by 6 months on ART compared to INSTI and PI recipients.

The banned sunscreen ingredients and their impact on human health: a systematic review

Recent evidence of high systemic absorption of sunscreen ingredients has raised concerns regarding the safety of sunscreen products. Oxybenzone (BP-3) and octinoxate (OMC), two common sunscreen ingredients, were recently banned in Key West and Hawaii owing to their toxic effects on marine ecosystems. Their impact on human health requires a careful assessment. To summarize the current evidence on the association between the systemic level of BP-3 or OMC and its health impact, a primary literature search was conducted using PubMed database in February 2019. There are 29 studies that address the impact of these ingredients on human health. Studies show that elevated systemic level of BP-3 has no adverse effect on male and female fertility, female reproductive hormone level, adiposity, fetal growth, child's neurodevelopment, and sexual maturation. However, the association of BP-3 level on thyroid hormone, testosterone level, kidney function, and pubertal timing has been reported and prompts further investigations to validate a true association. The systemic absorption of OMC has no reported effect on thyroid and reproductive hormone levels. In conclusion, current evidence is not sufficient to support the causal relationship between the elevated systemic level of BP-3 or OMC and adverse health outcomes. There are either contradictory findings among different studies or an insufficient number of studies to corroborate the observed association. To accurately evaluate the long-term risk of exposure to BP-3 and OMC from sunscreen, a well-designed longitudinal randomized controlled trial needs to be conducted.

Assessment of infectious complications in elderly kidney transplant recipients receiving induction with anti-thymocyte globulin vs basiliximab

BACKGROUND

Elderly transplant recipients experience lower rates of acute rejection with higher rates of infectious complications compared to their younger counterparts. While less intensive immunosuppression may be preferable, there are no recommendations for depleting versus non-depleting induction strategies. We sought to compare infectious complications between anti-thymocyte globulin (ATG) and basiliximab (IL2RA) induction in elderly kidney transplant recipients (KTRs).

METHODS

We reviewed 146 KTRs ≥65 years receiving ATG or IL2RA induction. Per institution protocol, ATG was administered to patients with the following characteristics, irrespective of age: African American (AA), PRA ≥20%, and/or re-transplantation. Infectious complications (bacterial, viral, and invasive fungal) at 1 year were compared.

RESULTS

There were significantly more AA, deceased donors, and sensitized KTRs in the ATG group, reflecting criteria for induction agent. ATG KTRs experienced higher rates of overall infectious complications (77% vs 56%, P = .01), driven by increased bacterial (54% vs 39%, P = .08) and viral infections (51% vs 35%, P = .05). Urinary tract infections (UTIs) and CMV in particular occurred at high rates among ATG patients (46% and 32%, respectively). In multivariate analysis, the only independent risk factor associated with increased risk for infection was induction with ATG (adjusted HR 1.71 [95% CI 1.04-2.83], P = .04). Overall rates of immunologic outcomes were low.

CONCLUSION

Elderly KTRs receiving ATG are at an increased risk for infectious complications, largely attributed to high rates of UTIs and CMV. Additional strategies aimed at mitigating these complications in elderly patients requiring ATG may be beneficial.

Massive clonal expansion of medulloblastoma-specific T cells during adoptive cellular therapy

In both human and murine systems, we have developed an adoptive cellular therapy platform against medulloblastoma and glioblastoma that uses dendritic cells pulsed with a tumor RNA transcriptome to expand polyclonal tumor-reactive T cells against a plurality of antigens within heterogeneous brain tumors. We demonstrate that peripheral TCR Vβ repertoire analysis after adoptive cellular therapy reveals that effective response to adoptive cellular therapy is concordant with massive in vivo expansion and persistence of tumor-specific T cell clones within the peripheral blood. In preclinical models of medulloblastoma and glioblastoma, and in a patient with relapsed medulloblastoma receiving adoptive cellular therapy, an early and massive expansion of tumor-reactive lymphocytes, coupled with prolonged persistence in the peripheral blood, is observed during effective therapeutic response to immunotherapy treatment.

Catamenial dermatoses associated with autoimmune, inflammatory, and systemic diseases: A systematic review,

Background

Sex hormones are important in female sexual physiology, growth, and homeostasis. Through skin receptors, sex hormones contribute to the dermatologic pathology known as catamenial dermatoses.

Objective

This study aims to summarize the literature on catamenial dermatoses and menses-induced exacerbations of chronic dermatoses.

Methods

This systematic review used the PRISMA method. PubMed was searched using the terms “menses” and “skin” in July 2018, and an assessment was conducted of the relevant literature on skin diseases related to non-pathologic menstruation, such as polycystic ovarian syndrome. Pathology associated with androgenetic acne was excluded from the study.

Results

A total of 102 studies with 1269 female patients were included. The most commonly reported primary catamenial dermatoses were autoimmune progesterone dermatitis and autoimmune estrogen dermatitis. The most commonly reported chronic skin disorders exacerbated by menses were psoriasis, Behcet’s disease, and eczematous dermatoses.

Conclusion

Physicians should be aware of the nature of catamenial dermatoses and their presentation with normal sexual physiology. Patients with chronic dermatoses should be appropriately counseled on menstruation-related exacerbations. Further research needs to be conducted to determine the interplay between immune regulation and sex hormones in catamenial dermatoses and to elucidate effective therapies.