Pharmacogenetics of weight gain following switch from efavirenz- to integrase inhibitor-containing regimens

BACKGROUND

Excessive weight gain affects some persons with HIV after switching to integrase strand transfer inhibitor (INSTI)-containing antiretroviral therapy (ART). We studied associations between CYP2B6 genotype and weight gain after ART switch among ACTG A5001 and A5322 participants.

METHODS

Eligible participants switched from efavirenz- to INSTI-containing ART, had genotype data, and had weight data at least once from 4 weeks to 2 years post-switch. Multivariable linear mixed effects models adjusted for race/ethnicity, CD4, age, BMI and INSTI type assessed relationships between CYP2B6 genotype and estimated differences in weight change.

RESULTS

A total of 159 eligible participants switched ART from 2007 to 2019, of whom 138 had plasma HIV-1 RNA < 200 copies/mL (65 CYP2B6 normal, 56 intermediate, 17 poor metabolizers). Among participants with switch HIV-1 RNA < 200 copies/mL, weight increased in all 3 CYP2B6 groups. The rate of weight gain was greater in CYP2B6 poor than in CYP2B6 normal metabolizers overall, and within 9 subgroups (male, female, White, Black, Hispanic, dolutegravir, elvitegravir, raltegravir, and TDF in the pre-switch regimen); only in Hispanic and elvitegravir subgroups were these associations statistically significant ( P  < 0.05). Compared to normal metabolizers, CYP2B6 intermediate status was not consistently associated with weight gain.

CONCLUSION

CYP2B6 poor metabolizer genotype was associated with greater weight gain after switch from efavirenz- to INSTI-containing ART, but results were inconsistent. Weight gain in this setting is likely complex and multifactorial.

An exploration of testicular cancer survivors' experience of ejaculatory dysfunction following retroperitoneal lymph node dissection-a sub-study of the PREPARE clinical trial

PURPOSE

Ejaculatory dysfunction secondary to retrograde ejaculation or anejaculation is a complication of retroperitoneal lymph node dissection (RPLND) for survivors of testicular cancer. We explored survivors' experiences of ejaculatory dysfunction following RPLND.

METHODS

In a sub-study of a single-arm phase 2 clinical trial (ACTRN12622000537752/12622000542796), participants reporting ejaculatory dysfunction ≥ 6 months following RPLND were invited to complete semi-structured interviews. Purposive sampling was used. Interviews continued until thematic saturation occurred, and codebook thematic analysis of interviews was performed.

RESULTS

Of 58 individuals recruited to the trial, 33 (57%) reported ejaculatory dysfunction. Of these, 32 (97%) agreed to interview and 15 participated. Participants interviewed had median age 34 years (range 24-66), 12 (80%) in a long-term relationship with median time from surgery 36 months (range 11-112). Three overarching themes were identified. The first reflected the value of RPLND despite ejaculatory dysfunction. The second illuminated the impact(s) of ejaculatory dysfunction closely mapped to life stage, with flow-on impacts to fertility, sex, psychological wellbeing and communication. The third reflected information needs. Fertility was a substantial source of concern for some participants. Ejaculatory dysfunction had no effect on sex for some, whilst for others, sex was less pleasurable. Some reported benefits. Few reported ejaculatory dysfunction challenged masculinity, confidence, or self-esteem.

CONCLUSIONS

Future research should examine interventions to reduce distress related to fertility, challenged masculinity and body image.

IMPLICATIONS FOR CANCER SURVIVORS

Whilst most participants considered ejaculatory dysfunction to have little impact on their sexual function and relationships, some reported significant difficulties varying by life stage and relationship status.

Efficacy of Alexa, Google Assistant, and Siri for Supporting Informed Prostate Cancer Screening Decisions for African-American Men

Prostate cancer is the most prevalent non-skin cancer among all men, but African-Americans have morbidity and mortality at significantly higher rates than White men. To reduce this burden, authorities such as the American Cancer Society recommend that men make informed/shared screening decisions with a healthcare provider. Informed/shared screening decisions require that men have adequate prostate cancer knowledge. Virtual assistants are interactive communication technologies that have become popular for seeking health information, though information quality has been mixed. No prior research has investigated the quality of prostate cancer information disseminated by virtual assistants. The purpose of this study was to determine the response rates, accuracy, breadth, and credibility of three popular virtual assistants (Alexa, Google Assistant, and Siri) for supporting informed/shared prostate cancer screening decisions for African-American men. Each virtual assistant was evaluated on a tablet, cell phone, and smart speaker using 12 frequently asked screening questions. Responses were rated dichotomously (i.e., yes/no), and analyses were conducted using SPSS. Alexa on a phone or tablet and Google Assistant on a smart speaker had the best overall performance based on a combination of response, accuracy, and credibility scores. All other assistants scored below 75% in one or more areas. Additionally, all virtual assistants lacked the breadth to support an informed/shared prostate cancer screening decision. African-American men may be especially disadvantaged by using virtual assistants for prostate cancer information because of the lack of emphasis on their greater disease risk, higher mortality rates, and appropriate ages at which they should begin screening conversations.

Assessing Leadership Behavior in Health Care: Introducing the Local Leadership Scale of the SCORE Survey

BACKGROUND

Engaged and accessible leadership is a key component of care excellence. However, the field lacks brief, reliable, and actionable measures of feedback and coaching-related behaviors of local leaders (for example, provides frequent feedback). The current study introduces a five-item Local Leadership (LL) scale by examining its psychometric properties, providing benchmarking across demographic factors and work settings, assessing its association with psychological safety, and testing whether LL predicts reports of restricted activities and absenteeism.

METHODS

In this cross-sectional study, 23,853 questionnaires were distributed across 31 Midwestern US hospitals. The survey included the LL scale, as well as safety culture and well-being scales. Psychometric analyses (Cronbach's α, confirmatory factor analysis [CFA] fit: root square mean error of the approximation [RMSEA], comparative fit index [CFI], Tucker-Lewis index [TLI]), Spearman correlations, t-tests, and analyses of variance (ANOVAs) were used to test the properties of the LL scale and differences by health care worker and work setting characteristics.

RESULTS

A total of 16,797 surveys were returned (70.4% response rate). The LL scale exhibited strong psychometric properties (Cronbach's α = 0.94; RMSEA = 0.079; CFI = 0.99; TLI = 0.98). LL scores differed by role, shift, shift length, and years in specialty. Of all roles, leaders (for example, managers) rated leaders most favorably. Nonclinical (vs. clinical) and nonsurgical (vs. surgical) work settings reported higher LL. LL scores correlated positively with psychological safety, absenteeism, and activities restricted due to illness.

CONCLUSION

The LL scale exhibits strong psychometric properties, convergent validity with psychological safety, and variation by work setting, work setting type, role, shift, shift length, and specialty. The study indicates that assessing leadership behaviors with the LL scale is useful and offers actionable behaviors for leaders to improve safety culture within teams.

Leadership Behavior Associations with Domains of Safety Culture, Engagement, and Health Care Worker Well-Being

BACKGROUND

Leadership is a key driver of health care worker well-being and engagement, and feedback is an essential leadership behavior. Methods for evaluating interaction norms of local leaders are not well developed. Moreover, associations between local leadership and related domains are poorly understood. This study sought to evaluate health care worker leadership behaviors in relation to burnout, safety culture, and engagement using the Local Leadership scale of the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey.

METHODS

The SCORE survey was administered to 31 Midwestern hospitals as part of a broad effort to measure care context, with domains including Local Leadership, Emotional Exhaustion/Burnout, Safety Climate, and Engagement. Mixed-effects hierarchical logistic regression was used to evaluate the relationships between local leadership scores and related domains, adjusted for role and work-setting characteristics.

RESULTS

Of the 23,853 distributed surveys, 16,797 (70.4%) were returned. Local leadership scores averaged 68.8 ± 29.1, with 7,338 (44.2%) reporting emotional exhaustion, 9,147 (55.9%) reporting concerning safety climate, 10,974 (68.4%) reporting concerning teamwork climate, 7,857 (47.5%) reporting high workload, and 3,436 (20.7%) reporting intentions to leave. Each 10-point increase in local leadership score was associated with odds ratios of 0.72 (95% confidence interval [CI] 0.71-0.73) for burnout, 0.48 (95% CI 0.47-0.49) for concerning safety climate, 0.64 (95% CI 0.63-0.66) for concerning teamwork climate, 0.90 (95% CI 0.89-0.92) for high workload, and 0.80 (95% CI 0.78-0.81) for intentions to leave, after adjustment for unit and provider characteristics.

CONCLUSION

Local leadership behaviors are readily measurable using a five-item scale and strongly associate with established domains of health care worker well-being, safety culture, and engagement.

Total Hip Arthroplasty in the Setting of Post-Traumatic Arthritis Following Acetabular Fracture: A Systematic Review

Background

Acetabular fractures are frequently associated with post-traumatic arthritis (PTA), for which total hip arthroplasty (THA) has emerged as the established procedure. The purpose of this systematic review is to report the patient outcomes, complications, and implant survival of delayed THA for patients with PTA following acetabular fracture.

Methods

A systematic review was performed in December 2021 as per Preferred Reporting Items for Systematic Review and Meta-Analysis Guidelines to identify all studies reporting outcomes of delayed THA performed for PTA with a history of acetabular fracture. From an initial screen of 893 studies, 29 studies which met defined inclusion criteria including minimum 12 months of follow-up and minimum 10 THA were included in the final review.

Results

A total of 1220 THA were reported across 29 studies, with 1174 THA completing a minimum of 1-year follow-up at a mean of 86 months. All 29 studies reported upon complications, with a control included in 6 for comparison. Higher complication rates were observed both in patients who had prior open reduction internal fixation and conservative treatment, most notably infection which was observed following 3.6% THA. The total joint revision rate was 9.7%. An improvement was noted in all 25 studies which recorded patient-reported outcomes, with a mean rise in the Harris hip score from 45 to 86 across 18 studies.

Conclusions

THA may reduce reported pain levels and improve functional outcomes in selected patients experiencing PTA following acetabular fractures. There is an increased risk of complications, necessitating careful consideration when planning the operation and open discussion with prospective patients and caregivers.

Evaluation of a health system's implementation of a monkeypox care model under the RE-AIM framework

Objective

Emerging infectious diseases challenge healthcare systems to implement new models of care. We aim to evaluate the rapid implementation of a new care model for monkeypox in our health system.

Design

This is a retrospective case series evaluation under the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework of implementation of a testing and care model for monkeypox in a large, integrated health system.

Methods

Atrium Health implemented education of providers, testing protocols, and management of potential monkeypox cases using electronic health record (EHR) data capabilities, telehealth, and collaboration between multiple disciplines. The first 4 weeks of care model implementation were evaluated under the RE-AIM framework.

Results

One hundred fifty-three patients were tested for monkeypox by 117 unique providers at urgent care, emergency departments, and infectious disease clinics in our healthcare system between 18 July 2022 and 14 August 2022. Fifty-eight monkeypox cases were identified, compared with 198 cases in the state during the time period, a disproportionate number compared with the health system service area, and 52 patients were assessed for need for tecovirimat treatment. The number of tests performed and providers sending tests increased during the study period.

Conclusion

Implementation of a dedicated care model leveraging EHR data support, telehealth, and cross-disciplinary collaboration led to more effective identification and management of emerging infectious diseases and is important for public health.

Plain Language Summary

Impact of care model implementation on monkeypox New infectious diseases challenge health systems to implement new care practices. Our health system responded to this challenge by implementing a care model for education, testing, and clinical care of monkeypox patients. We analyzed results from implementing the model. We were able to identify a disproportionate number of monkeypox cases compared with the rest of our state by using our model to educate medical providers, encourage testing, and ensure patients had access to best disease care. Implementation of care models for testing and management of new diseases will improve patient care and public health.

1424. Central Nervous System Tuberculosis in a Large Healthcare System

Background

Central nervous system tuberculosis (CNS-TB) accounts for 5-10% of extrapulmonary TB cases. It takes 3 clinical forms: meningitis, tuberculoma, and arachnoiditis. Modern case descriptions of the presentation of CNS-TB are rare. The goal of this study is to examine the presentation, diagnostic studies, and associated comorbidities of CNS-TB.

Methods

In our academic healthcare system, cases of culture confirmed CNS-TB were identified in a database maintained by the infection control group. This is a retrospective case series of the 11 adults with confirmed CNS-TB.

Results

273 patients were identified with TB infection from 2008 to 2022. 104 (38%) had extra pulmonary disease. 11 (4%) had CNS infection. Patient characteristics are described in Table 1. 5 (45%) of the patients with CNS disease also had pulmonary disease. Mean age of diagnosis was 42. 5 (45%) were male and 9 (82%) were African American. 5 (45%) had HIV; mean CD4 count was 100 (8-255). Diagnostics are shown in Table 2. CSF studies revealed a mean WBC of 295/mm3 (4-808), protein of 605 mg/dL (27-4476), and Glucose of 31 (12-64) mg/dL. 4 (36%) patients presented with British Research Medical Council (BMRC) clinical stage I disease and 7 (64%) with stage II disease. 8 (73%) patients had an abnormal CT or MRI scan of the head, with representative images seen in Figure 1. 5 patients (45%) had lesions consistent with tuberculomas. 1 (9%) had arachnoiditis identified on imaging. 1 (9%) patient died.

Conclusion

38% of patients diagnosed with TB at our center had extrapulmonary disease compared to 17.5% reported in the literature. The 4% rate of CNS-TB was similar to previously reported. Our series describes abnormal imaging as well as CSF studies showing leukocytosis, pleocytosis, and hypoglycorrhachia consistent with previously described findings. Though numbers were small, no significant difference was found between HIV positive and negative patients. Although mortality was rare in our series, the patient who died had advanced AIDS and multidrug resistant meningitis. Given the significant global mortality of this disease, this series highlights the need for more current studies describing the presentation and diagnostic characteristics of modern CNS-TB so clinicians can better recognize and treat the condition without delay.

Disclosures

All Authors: No reported disclosures.

2083. HIV Testing Rates in NC Emergency Departments Before and During Covid Mitigation

Background

During the early stages of the COVID-19 pandemic, non-emergent services were limited or suspended in multiple ways. Restrictions in primary care may have limited STI testing, such as HIV, where timely access to testing and care is critical to mitigation efforts. Conversely, Emergency Departments (ED) operated with fewer restrictions and more in-person options. Even though patient census numbers decreased in some areas from those seen pre-covid lockdown, EDs and hospitals often became overwhelmed with patients seeking care for both severe acute illness but just importantly services that might normally have been received in outpatient settings.

Methods

Observational study of HIV screening year-over-year in four EDs that are part of a large healthcare system located in the Southeast. Screenings of individuals 18 and over seen in the EDs were normalized per 1000 patients. Rates were also compared to two primary care clinics, located in the same metropolitan area, serving mainly Medicaid and uninsured patients.

Results

From March 2019 through February 2020 there were 33.47 tests per 1000 patients at two community clinics and 7.79 tests per 1000 patient at four EDs located in the same region during that span. From March 2020 to February 2021, screening numbers in the primary care clinics dropped to an average of 22.7/1000; however, screenings in the ED remained stable and slightly increased to 10.7/1000. From March 2021 to February 2022, screenings in the primary care clinics returned to an average 36.9/1000 with screenings in the ED still above pre-covid levels at 9.48/1000. These trends in the ED screening remained consistent across gender, race, and ethnicity.

Patient census at four ED sites located in the southwestern region of North Carolina dropped significantly during the first year of physical distancing covid-19 mitigation measures when compared to the two years prior. These census numbers increased during the second year of covid-19 but failed to return to previous levels.

During the first year of physical distancing covid-19 mitigation measures HIV testing rates in the emergency department remained constant, and even increased in more urban areas, despite the significant decrease in overall patient census.

Conclusion

With the observation that HIV screening decreased in primary care settings during the beginning of the covid-19 pandemic, there exists the possibility that new HIV infections may yet remain undiagnosed. That HIV testing remained constant in the ED, however, reinforces the importance of having embedded procedures in place for screening and linking both newly positive and at-risk patients into care to help mitigate the HIV epidemic.

Disclosures

All Authors: No reported disclosures.

Erdheim-Chester disease presenting as meningitis with hypoglycorrhachia: A case report

INTRODUCTION

Erdheim-Chester disease (ECD) commonly has neurologic manifestations but rarely presents with meningitis and hypoglycorrhachia. Here, were present a case of ECD with a clinical and laboratory presentation initially thought to be bacterial meningitis with sepsis.

METHODS

We report a case of a 79-year-old with history of enigmatic bone pain and peritoneal nodules who presented with meningitis. After failure to improve on antibiotic therapy other etiologies of hypoglycorrhachia including sarcoid, tuberculosis, and fungal and carcinomatous meningitis were considered. However, no definite diagnosis could be made based on radiologic, serologic, microbiologic, and molecular testing and the patient failed to improve on empiric therapy including antibiotics, antifungals, and tuberculosis and steroid therapy.

RESULTS

Ultimately, autopsy revealed a new diagnosis of ECD manifesting as meningitis, a rare presentation of a rare disease.

CONCLUSION

Although only reported in one other case to our knowledge, ECD can present with meningitis with hypoglycorrhachia.

Patient-Centered Treatment of Chronic Migraine With Medication Overuse: A Prospective, Randomized, Pragmatic Clinical Trial

BACKGROUND AND OBJECTIVES

Overuse of symptomatic (i.e., acute) medications is common among those with chronic migraine. It is associated with developing frequent headaches, medication side effects, and reduced quality of life. The optimal treatment strategy for patients who have chronic migraine with medication overuse (CMMO) has long been debated. The study objective was to determine whether migraine preventive therapy without switching or limiting the frequency of the overused medication was noninferior to migraine preventive therapy with switching from the overused medication to an alternative medication that could be used on ≤2 d/wk.

METHODS

The Medication Overuse Treatment Strategy (MOTS) trial was an open-label, pragmatic clinical trial, randomizing adult participants 1:1 to migraine preventive medication and (1) switching from the overused medication to an alternative used ≤2 d/wk or (2) continuation of the overused medication with no maximum limit. Participants were enrolled between February 2017 and December 2020 from 34 clinics in the United States, including headache specialty, general neurology, and primary care clinics. The primary outcome was moderate to severe headache day frequency during weeks 9 to 12 and subsequently during weeks 1 to 2 after randomization.

RESULTS

Seven hundred twenty participants were randomized; average age was 44 (SD 13) years; and 87.5% were female. At baseline, participants averaged 22.5 (SD 5.1) headache days over 4 weeks, including 12.8 (SD 6.7) moderate to severe headache days and 21.4 (SD 5.8) days of symptomatic medication use. Migraine preventive medication without switching of the overused medication was not inferior to preventive medication with switching for moderate to severe headache day frequency during weeks 9 to 12 (switching 9.3 [SD 7.2] vs no switching 9.1 [SD 6.8]; p = 0.75, 95% CI -1.0 to 1.3). The treatment strategies also provided similar outcomes during the first 2 weeks (switching 6.6 [SD 3.7] moderate to severe headaches days vs no switching 6.4 [SD 3.6]; p = 0.57, 95% CI -0.4 to 0.7).

DISCUSSION

When reduction in moderate to severe headache days was used as the outcome of interest for the management of CMMO, migraine preventive medication without switching or limiting symptomatic medication is not inferior to migraine preventive medication with switching to a different symptomatic medication with a maximum limit of 2 treatment days per week.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov identifier NCT02764320.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that, for patients who have CMMO, migraine preventive medication without switching or limiting the overused medication is noninferior to migraine preventive medication with switching and limiting symptomatic medication.

Comparing race and ethnicity across safety-net and non-safety net practices pre- and post-an HIV screening alert

CONTEXT: Societal and economic burdens of human immunodeficiency virus (HIV) continue to grow, even as treatments and prevention for this disease becomes more readily available and efficacious. HIV screening is more likely to be performed in minority (including Black) patient populations compared to whites. The likelihood of getting screened also depends on primary care practice attributes. OBJECTIVE: Evaluate HIV screening demographics by safety-net and non-safety net practices. STUDY DESIGN and ANALYSIS: Pre-post analysis. SETTING: Atrium Health is a non-profit, vertically integrated healthcare system with approximately 16 million patient encounters per year across the Southeast US. POPULATION STUDIED: Twelve primary care practices, including four safety-net practices serving predominantly Medicaid and uninsured patients, with over 115,00 patients between the ages of 18 and 64 were selected for the educational intervention. INTERVENTION/INSTRUMENT: A system-wide electronic medical record alert prompting HIV screening was implemented in October 2017 targeting adults between 18-64 years old. In addition to the system alert, a provider peer-to-peer educational program detailing HIV disease epidemiology, screening recommendations, and algorithms to guide screening efforts was developed. OUTCOME MEASURES: HIV screenings. RESULTS: From October 2016- April 2017, 3,413 patients were screened for HIV at the twelve participating primary care practices. Immediately after the HIV alert activation, from October 2017 - April 2018, 6,256 patients were screened, resulting in an 83% increase in screening. However, increases were different based on practice type, race and ethnicity. Black patients in safety net clinics had higher screening rates prior to the alert and showed less of an increase in screening (37%) compared to whites (102%) after the alert was activated. Hispanic/Latino patients showed similar increases at both safety net (99%) and non-safety net (108%) practices. Both Black and white patients showed larger increases of 99% and 139% in non-safety net clinics. Chi-squared analysis comparing the percentage of patients screened during these time periods was significantly different (p=0.001). CONCLUSION: While race and practice characteristics influence the likelihood of HIV screening, EMR modifications and provider education can significantly enhance screening and care for patients with HIV regardless of race and practice type.

285. Outcomes and Antibiotic Use in Patients with COVID-19 Admitted to an Intensive Care Unit

Background

Studies have shown the proportion of critically ill patients with COVID-19 receiving empiric antibiotics (ABX) greatly exceeds those with culture-proven bacterial co-infections. However, the benefits of continuing ABX in culture-negative (CxN) cases is unknown; this practice may increase the risks associated with ABX overuse. The purpose of this study was to evaluate outcomes and antibiotic use (AU) in intensive care unit (ICU) patients with COVID-19 based on culture results.

Methods

This was a multicenter, retrospective cohort study evaluating adults in an ICU for the first episode of ABX initiated following a confirmed COVID-19 diagnosis between September to December 2020. Blood and/or respiratory cultures must have been obtained within 24 hours (h) of ABX initiation. Patients were categorized into three groups: 1) CxN, ABX discontinued ≤ 72 h, 2) CxN, ABX continued > 72 h, or 3) Culture-positive (CxP). Data on AU was obtained from electronic medication administration records. The primary outcome was clinical success, defined as being discharged alive or > 2-point decrease in the World Health Organization Clinical Progression Scale score from day of ABX initiation to day 30.

Results

A total of 65 patients were included with 35.4% being CxP. ABX were discontinued ≤ 72 h in 23.8% of CxN patients. Methicillin-susceptible Staphylococcus aureus was the most common organism in 52.2% of CxP patients (66.7% respiratory; 16.7% blood; 16.7% both). Anti-methicillin-resistant Staphylococcus aureus and anti-pseudomonal antibiotics were the most prescribed for the initial regimen (Table 1). ABX de-escalation occurred in 58.5% of patients. Initial ABX duration was significantly longer in the CxP group (P < 0.01). No significant difference in clinical success was observed (Table 2). Although not significantly different, the highest rate of adverse events occurred in the CxN and ABX continued > 72 h group (40.6%).

Table 1. Antibiotic Use in ICU Patients with COVID-19

Table 2. Clinical Outcomes and Adverse Events in ICU Patients with COVID-19

Conclusion

In ICU patients with COVID-19, empiric broad-spectrum ABX are often overutilized with an inertia to de-escalate despite negative culture results, potentially increasing the risk of adverse events. This remains an important area for focused antimicrobial stewardship efforts to mitigate the development of multidrug resistance.

Disclosures

Christopher Polk, MD, Atea (Research Grant or Support)Gilead (Advisor or Review Panel member, Research Grant or Support)Humanigen (Research Grant or Support)Regeneron (Research Grant or Support)

550. Bamlanivimab and Casirivimab/Imdevimab Treatment Outcomes: Results from a Large Healthcare System’s Structured Implementation Experience

Background

Neutralizing antibody therapies targeting SARS-CoV-2 have been released for emergency use authorization by the FDA. Little is published on their real-world experience. In this retrospective study we share the results of our early experience on patient outcomes from use of these neutralizing antibodies within a large healthcare system.

Methods

We retrospectively analyzed results of a healthcare system wide program to pro-actively identify and treat COVID-19 patients with neutralizing antibody therapy.

Results

The 449 patients identified for SARS-CoV-2 neutralizing antibody therapy during the study period were retrospectively classified as falling in one of the three groups: untreated (199), bamlanivimab (87) and casirivimab/indevimab (125) treated patients (Table 1). Reasons identified patients were not treated most commonly were patient declined (n=74), unable to be contacted (n=36), out of treatment window (n=23), asymptomatic and feeling better (n=21) or did not have transportation (n=9). Bamlanivimab infusion did not reduce emergency room (ER) visits or hospitalization compared to untreated patient within 30-days of follow up (Table 2), and among all patients treated with antibody therapy only treatment with bamlanivimab and non-white race were predictors of need for hospitalization (Table 3). Casirivimab/indevimab did reduce subsequent ER visits or hospitalization within 30 days post-infusion when compared to the untreated group. However, patients treated with either antibody therapy had lower acuity of COVID-19 disease as reflected in need for intensive care unit (ICU) stay, mechanical ventilation or death (Table 2).

Table 1. Characteristics of infused vs uninfused patients

Table 2. Outcomes in treated vs untreated patients

Table 3. Risk factors for ED visits or hospitalization in infused patients

Conclusion

Either neutralizing antibody therapy appears to markedly reduce acuity of COVID-19 disease even if patients do progress to requiring hospitalization. However, casirivimab/indevimab therapy also decreased ER visits and hospitalization suggesting better efficacy in our experience.

Disclosures

Christopher Polk, MD, Atea (Research Grant or Support)Gilead (Advisor or Review Panel member, Research Grant or Support)Humanigen (Research Grant or Support)Regeneron (Research Grant or Support) Mindy Sampson, MD, Regeneron (Grant/Research Support)

Optimal timing and technique for endoscopic management of dysphagia in pediatric aerodigestive patients

INTRODUCTION

The best strategy to manage an interarytenoid defect [Type 1 laryngeal cleft (LC-1) or deep interarytenoid groove (DIG)] in pediatric aerodigestive patients with dysphagia remains uncertain. This study compared benefit of interarytenoid augmentation (IAA) to suture repair or clinical observation alone in pediatric patients.

METHODS

A 3-year retrospective, single-center analysis of children with dysphagia undergoing endoscopic airway evaluation was performed. Physician preference guided treatment plan: suture repair with CO2 laser, IAA (carboxy methylcellulose or calcium hydroxyapatite), or observation. Primary outcome was improved post-operative diet. Significance was assumed at p < 0.05.

RESULTS

449 patients underwent diagnostic endoscopy. Mean age (±SD) at procedure was 21 ± 13 months, with nearly one fourth (28 %) of children ≤ 12 months. Eighty (18 %) had either an LC-1 (n = 55) or DIG (n = 25). Of these, 35 (42 %) underwent suture repair, 22 (28 %) IAA, and 23 (30 %) observation only. Aspiration improved overall in the interventional groups compared to observational controls (58 % vs. 9 %, p < 0.05), with no change in benefit observed by age of intervention. IAA was as effective as suture repair (59 % vs 55 %, p = 0.46). In patients with only a DIG, IAA intervention alone significantly improved swallow function (66.6 % vs. 0 %, p < 0.05).

CONCLUSION

In pediatric aerodigestive patients with dysphagia, 18 % of children have an addressable lesion. IAA or suture repair similarly improves dietary advancement. IAA improves swallow function in patients with DIG. These findings support a novel protocol to intervene in dysphagia patients with LC-1 or DIG via IAA at the initial operative evaluation.

Safety Culture and Workforce Well-Being Associations with Positive Leadership WalkRounds

BACKGROUND

Interventions to decrease burnout and increase well-being in health care workers (HCWs) and improve organizational safety culture are urgently needed. This study was conducted to determine the association between Positive Leadership WalkRounds (PosWR), an organizational practice in which leaders conduct rounds and ask staff about what is going well, and HCW well-being and organizational safety culture.

METHODS

This study was conducted in a large academic health care system in which senior leaders were encouraged to conduct PosWR. The researchers used data from a routine cross-sectional survey of clinical and nonclinical HCWs, which included a question about recall of exposure of HCWs to PosWR: "Do senior leaders ask for information about what is going well in this work setting (e.g., people who deserve special recognition for going above and beyond, celebration of successes, etc.)?"-along with measures of well-being and safety culture. T-tests compared work settings in the first and fourth quartiles for PosWR exposure across SCORE (Safety, Communication, Operational Reliability, and Engagement) domains of safety culture and workforce well-being.

RESULTS

Electronic surveys were returned by 10,627 out of 13,040 possible respondents (response rate 81.5%) from 396 work settings. Exposure to PosWR was reported by 63.1% of respondents overall, with a mean of 63.4% (standard deviation = 20.0) across work settings. Exposure to PosWR was most commonly reported by HCWs in leadership roles (83.8%). Compared to work settings in the fourth (< 50%) quartile for PosWR exposure, those in the first (> 88%) quartile revealed a higher percentage of respondents reporting good patient safety norms (49.6% vs. 69.6%, p < 0.001); good readiness to engage in quality improvement activities (60.6% vs. 76.6%, p < 0.001); good leadership accessibility and feedback behavior (51.9% vs. 67.2%, p < 0.001); good teamwork norms (36.8% vs. 52.7%, p < 0.001); and good work-life balance norms (61.9% vs. 68.9%, p = 0.003). Compared to the fourth quartile, the first quartile had a lower percentage of respondents reporting emotional exhaustion in themselves (45.9% vs. 32.4%, p < 0.001), and in their colleagues (60.5% vs. 47.7%, p < 0.001).

CONCLUSION

Exposure to PosWR was associated with better HCW well-being and safety culture.

Impact of the COVID-19 Pandemic on Pelvic and Acetabular Trauma: Experiences From a National Tertiary Referral Centre

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on daily life. Restrictions imposed to help minimise virus transmission have limited both population movement and employment, as well as altering the potential mechanisms of high-energy trauma. The objective of this study was to assess the impact of the COVID-19 pandemic on pelvic and acetabular trauma.

Materials and methods

A retrospective observational study of the incidence, causality, patient profile, fracture morphology, and treatment strategy of pelvic and acetabular trauma managed in a national tertiary referral specialist pelvic and acetabular centre between the 1^st of March and 1^st of August 2020 was undertaken and compared to corresponding time periods in the two preceding years.

Results

A total of 78 patients were referred for management following pelvic and acetabular trauma during the study period with a mean age of 52 years (SD +/- 24.2). Overall, 45% and 42% of patients were referred following isolated pelvic or acetabular fractures respectively. The most frequent mechanism of injury was a fall from height (>1m) (42%), with 53% of patients suffering from concomitant injuries and 32% requiring surgical management. While there was a statistically significant difference in mechanism of injury (P=0.026), there was no significant difference in overall incidence, fracture types, incidence of concomitant injuries, or overall proportion requiring surgical intervention during the study period when compared to previous years.

Conclusion

While some variation in the mechanisms of injury have been observed, the overall incidence, patient, fracture, and injury profiles associated with pelvic and acetabular trauma appear to have remained consistent during the COVID-19 pandemic. Additionally, the number and proportion of those requiring surgical treatment of these fractures have remained stable. Understanding the continued burden of these potentially severe injuries may help guide injury prevention, treatment, and resource allocation as the pandemic continues.

Successful Use of Telemedicine Infectious Diseases Consultation With an Antimicrobial Stewardship-Led Staphylococcus aureus Bacteremia Care Bundle

Background

Telemedicine (TM) programs can be implemented to deliver specialty care through virtual platforms and overcome geographic/resource constraints. Few data exist to describe outcomes associated with TM-based infectious diseases (ID) management. The purpose of this study was to compare outcomes associated with TM and onsite standard-of-care (SOC) ID consultation after implementation of an antimicrobial stewardship (AMS)-led Staphylococcus aureus bacteremia (SAB) bundle.

Methods

A retrospective cohort study was conducted on the effects of a SAB bundle comparing ID consult delivery (SOC or TM) at 10 US hospitals within Atrium Health in adult patients admitted from September 2016 through December 2017. The type of ID consult provided was based on the admitting hospital; no hospital had both modalities. Bundle components included the following: (1) ID consult, (2) appropriate antibiotics, (3) repeat blood cultures until clearance, (4) echocardiogram obtainment, and (5) appropriate antibiotic duration. The AMS facilitated bundle initiation and compliance. The primary outcome was bundle adherence between groups. Differences in clinical outcomes were also assessed.

Results

We evaluated 738 patients with SAB (576 with SOC, 162 with TM ID). No differences were observed in overall bundle adherence (SOC 86% vs TM 89%, P = .33). In addition, no significant differences resulted between groups for hospital mortality, 30-day SAB-related readmission, persistent bacteremia, and culture clearance. Groups did not differ in 30-day mortality when controlling for demographics, bacteremia source, and physiological measures with multivariable logistic regression.

Conclusions

Our findings provide evidence to support effective use of TM ID consultation and AMS-led care bundles for SAB management in resource-limited settings.

Pelvic and acetabular trauma in amateur equestrian enthusiasts - A retrospective review

INTRODUCTION

Horse riding related accidents can present with devastating pelvic and acetabular fractures. This study examines the nature, management and treatment outcomes of severe pelvic and acetabular trauma in amateur horse riders presenting to a national tertiary referral centre. We also aim to define certain at-risk groups.

METHODS

This was a retrospective descriptive cohort of all patients who were referred to the National Centre for Pelvic and Acetabular trauma resulting from horse riding accidents. All patients who were referred to the National Centre for Pelvic and Acetabular Trauma between January 2018 and July 2020 were included. Professional horse riders were excluded. Clinical and treatment outcome measures were stratified to four different mechanisms of injury: fall from horse (FFH), horse crush (HC), Horse Kick (HK) and Saddle Injury (SI).

RESULTS

There were 31 equestrian related injuries referred to our centre between January 2018 and July 2020. One patient was a professional jockey and was thus excluded from the study. Eighteen were female and the mean age at referral was 37 years old. The majority of these were pelvic ring injuries (73%). Fifty per cent of patients required surgical intervention and the majority of these were male.

CONCLUSION

Horse riding is a potentially dangerous recreational pursuit with significant risk of devastating injury. Pelvic and acetabular fractures secondary to horse riding are frequently associated with other injuries and the need operative intervention is common in this group. Young women and older men are higher risk groups.

Implementation of a comprehensive intervention focused on hospitalized patients with HIV by an existing stewardship program: successes and lessons learned

Background:

Several national organizations have advocated for inpatient antiretroviral stewardship to prevent the consequences of medication-related errors. This study aimed to evaluate the impact of a stewardship initiative on outcomes in people with HIV (PWH).

Methods:

A pharmacist-led audit and review of adult patients admitted with an ICD-10 code for HIV was implemented to an existing antimicrobial stewardship program. A quasi-experimental, retrospective cohort study was conducted comparing PWH admitted during pre- and post-intervention periods. Rates of antiretroviral therapy (ART)-related errors and infectious diseases (ID) consultation with linkage to care were evaluated through selection of a random sample of patients receiving ART in each period. Length of stay (LOS) and mortality were assessed by analyzing all admissions in the post-intervention period. Clinical outcomes including LOS, 30-day all-cause hospital readmission, and in-hospital and 30-day mortality in the post-intervention group were stratified by patients not on ART, on ART at admission, and started on ART as a result of the intervention.

Results:

A total of 100 patients in the pre-intervention period and 103 patients in the post-intervention period were included to assess ART-related errors and linkage to care. A reduction in errors (70.0 versus 25.7%, p < 0.001) and increased linkage to care (19.0 versus 39.6%, p < 0.01) were demonstrated. Of 389 admissions during the post-intervention period, 30-day mortality rates were similar between PWH on ART at admission and those initiated on ART during admission (5% versus 8%, respectively), but less than those not on ART (21%). A longer LOS was observed in the patients started on ART during admission (5 days if ART started during admission versus 3 days if not started during admission, p < 0.01).

Conclusions:

This interdisciplinary intervention was successful in reducing inpatient ART-related errors and increasing ID consultation with linkage to care among PWH.

Globally observed trends in mean and extreme river flow attributed to climate change

Anthropogenic climate change is expected to affect global river flow. Here, we analyze time series of low, mean, and high river flows from 7250 observatories around the world covering the years 1971 to 2010. We identify spatially complex trend patterns, where some regions are drying and others are wetting consistently across low, mean, and high flows. Trends computed from state-of-the-art model simulations are consistent with the observations only if radiative forcing that accounts for anthropogenic climate change is considered. Simulated effects of water and land management do not suffice to reproduce the observed trend pattern. Thus, the analysis provides clear evidence for the role of externally forced climate change as a causal driver of recent trends in mean and extreme river flow at the global scale.

Mitochondrial DNA haplogroups and weight gain following switch to integrase strand transfer inhibitor-based antiretroviral therapy

BACKGROUND

Integrase strand transfer inhibitor (INSTI)-based antiretroviral therapy (ART) has been associated with excess weight gain in some adults, which may be influenced by genetic factors. We assessed mitochondrial DNA (mtDNA) haplogroups and weight gain following switch to INSTI-based ART.

METHODS

All AIDS Clinical Trials Group A5001 and A5322 participants with mtDNA genotyping who switched to INSTI were included. mtDNA haplogroups were derived from prior genotyping algorithms. Race/ethnicity-stratified piecewise linear mixed effects models assessed the relationship between mtDNA haplogroup and weight change slope differences before and after switch to INSTI.

RESULTS

A total of 291 adults switched to INSTI: 78% male, 50% non-Hispanic White, 28% non-Hispanic Black, and 22% Hispanic. The most common European haplogroups were H [n = 66 (45%)] and UK [32 (22%)]. Non-H European haplogroups had a significant increase in weight slope after the switch. This difference was greatest among non-H clade UK on INSTI-based regimens that included tenofovir alafenamide (TAF) [3.67 (95% confidence interval 1.12, 6.21) kg/year; P = 0.005]. Although small sample size limited analyses among non-Hispanic Black and Hispanic persons, similarly significant weight gain was seen among the most common African haplogroup, L3 [n = 29 (39%); slope difference 4.93 (1.54, 8.32) kg/year, P = 0.005], after switching to TAF-containing INSTI-based ART.

CONCLUSION

Those in European mtDNA haplogroup clade UK and African haplogroup L3 had significantly greater weight gain after switching to INSTI-based ART, especially those receiving TAF. Additional studies in large and diverse populations are needed to clarify the mechanisms and host risk factors for weight gain after switching to INSTI-based ART, with and without TAF.

1655. Extrapulmonary Tuberculosis in a Large Healthcare System

Background

The US has seen a rise in the proportion of patients with extrapulmonary tuberculosis (TB) even though the yearly incidence of new TB cases has been in decline. The purpose of this study was to analyze incidence of extrapulmonary TB at Atrium Health, a large non-profit health system in the Southeastern US.

Methods

Retrospective chart review of 94 adult patients with culture confirmed extrapulmonary TB between 2008-2019. Individuals younger than 18 years were excluded from analysis. The primary objective was to examine incidence of extrapulmonary TB and compare it to that reported in the literature. Secondary objectives included determination of sites of extrapulmonary disease and associated patient characteristics including HIV status, race, ethnicity, and birthplace.

Results

237 patients were identified as having confirmed TB infection from 2008-2019 in a retrospective analysis within the Atrium Health System. 94 (40%) were found to have extrapulmonary disease; 42 (45%) with concomitant pulmonary disease. The patients were 55% male, 40% African American, 21% Hispanic or Latino, and 51% US-born. Median age was 44 years (range 20-62). The most common sites of extrapulmonary TB were lymphatic (35%), pleural (24%), GI/Peritoneal (12%), CNS (10%), and Bone/Joint (10%). Lymphatic involvement was 40% cervical, 19% intrathoracic, and 16% axillary. 66% of skeletal disease was vertebral. Other sites included GU, pericardial, skin, and disseminated disease (5%). 37% were HIV positive, 18% with unknown HIV status as they were never tested. Information regarding patient’s race, ethnicity, and birthplace were unknown for 2 patients. The percentage of extrapulmonary cases were 29% in 2008, 39% in 2012, 38% in 2016, and 49% in 2019.

Conclusion

Lymphatic and pleural involvement were the most common extrapulmonary sites. Of those tested, 37% were HIV positive but there was a significant portion never tested showing a need for increased testing. The proportion of extrapulmonary TB cases since 2008 is higher at 40% compared to the 31% reported in the United States. There has been a rise in the proportion of extrapulmonary TB within our healthcare system and deserves further analysis.

Disclosures

All Authors: No reported disclosures

1657. Musculoskeletal Tuberculosis in a Large Healthcare System

Background

Musculoskeletal tuberculosis (TB) is an important and elusive manifestation of extrapulmonary TB. This purpose of this study was to examine incidence and associated co-morbidities of confirmed cases of musculoskeletal TB at Atrium Health, a large non-profit health system in the Southeastern United States.

Methods

Retrospective case series of 12 adult patients with confirmed musculoskeletal TB between 2008-2019. Individuals younger than 18 years were excluded. The primary objective was to compare local incidence of musculoskeletal TB with that reported in the literature. Secondary objectives included analysis of patient co-morbidities for their correlation with the development of musculoskeletal manifestations of TB and requirement of surgical correction for underlying deformities from TB infection.

Results

237 patients were identified with confirmed TB infection from 2008-2019 in a retrospective cohort within the Atrium Health System. Of 237 patients, 94 (40%) had extrapulmonary disease and 12 (5%) had musculoskeletal manifestations defined as involvement of bone, joint space, or muscle and were included in this analysis. Six (50%) of the 12 patients were foreign born individuals who immigrated to the US. Three (33%) had concomitant pulmonary disease. Vertebral involvement (8, 66%) was most common and 1 (8%) patient noted to have infected total knee arthroplasty. Other sites included wrist, sternum, ribs and pelvis. Co-morbidities evaluated included HIV status 0%, diabetes (2, 17%), immunosuppressive medications (1, 8%), ESRD 0%, and rheumatologic disease 0%. Surgical intervention was necessary in 4 (33%) patients for both diagnostic and therapeutic interventions.

Conclusion

Of those tested for HIV 100% were negative but only 50% were tested showing a need for improved HIV testing. Very few had other co-morbid conditions including diabetes, use of immunosuppressive medications, ESRD status, or rheumatologic disease. Surgical intervention was needed in 33% of patients with musculoskeletal TB including several with a preoperative suspected diagnosis of malignancy. In this retrospective case series, the incidence of musculoskeletal TB was 5% in comparison to the 2-3% reported consistently in the US.

Disclosures

All Authors: No reported disclosures

553. Critically Ill patients Receiving Tocilizumab Compared With Those Not Receiving Tocilizumab for Treatment of COVID-19

Background

Background::

Immune modulation in patients with clinical features suggestive of a cytokine release syndrome (CRS) has become a pharmacologic target for potential treatment of COVID-19 and prevention of ARDS. Tocilizumab is an IL-6 receptor blocker FDA-approved for chimeric antigen receptor (CAR) T cell-induced severe or life-threatening CRS. The objective of this study was to describe clinical outcomes associated with tocilizumab compared with those not receiving tocilizumab in critically ill patients with severe COVID-19.

Methods

Methods:

Retrospective case series of 49 adult patients admitted to an intensive care unit with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Patients receiving tocilizumab were compared with those not receiving tocilizumab. The primary outcome was clinical improvement (decrease in supplemental oxygen requirement, discharge from ICU, or live discharge from hospital). Secondary endpoints included mortality and frequency of extubation. All comparative endpoints were assessed at 2 weeks after ICU admission.

Results

Results:

49 patients were identified with SARS-CoV-2 who were admitted to an ICU, 16 received tocilizumab. Baseline characteristics were similar; most were African American males with comorbidities such as obesity, cardiovascular disease, and diabetes. The time from symptom onset to positive test and subsequent intubation were similar (4 and 7 days, respectively). 75% received one dose (all received 8 mg/kg). The median time from symptom onset to tocilizumab administration was 11 days.

In patients receiving tocilizumab compared with those not receiving tocilizumab, there were similar rates of clinical improvement (44% versus 61%, p=0.27), extubation (31% versus 45%, p=0.60), and mortality (18% versus 19%, p &gt;0.99, respectively). 81% of the tocilizumab group had resolution of fever and 75% had improvement in C-reactive protein levels.

Conclusion

Conclusion:

In this study of patients with progressed disease, outcomes were similar regardless of receipt of tocilizumab. Randomized controlled trials are needed to assess the impact of earlier administration and identify clinical characteristics to assist with selection of appropriate patients who may benefit from tocilizumab.

Disclosures

All Authors: No reported disclosures

1004. Clinical Decision Support System Alerts for HIV Retention in Care – A Pilot Implementation Research Study

Background

Clinical decision support system (CDSS) alerts may help retain people living with HIV (PLWH) in care. A system of CDSS alerts utilizing the CHORUS™ portal was developed to identify PLWH at risk of being lost to care. To evaluate feasibility for a larger scale study, a before and after implementation research pilot study was implemented in the OPERA Cohort at three clinic sites in a southeastern US city.

Methods

Periods without intervention (before) or with CDSS alerts (after) were followed by 3 months of follow up. The study population consisted of PLWH with ≥ 1 electronic health record entry in the 2 years prior to, or during, the before or after period (Fig 1). To support clinicians through a discrete implementation strategy, alerts warning of suboptimal patient attendance were generated daily for the eligible PLWH at each site; providers or other clinic staff could respond to the alerts (Fig 2). Alerts, responses, and visits (i.e., meeting with provider or HIV lab measurement) were characterized. The proportion of PLWH with ≥ 1 visit in the before and after periods were compared at each site by Pearson’s Chi-square.

Figure 1. Pilot study timeline

Figure 2. CDSS alert criteria and response options

Results

A total of 12,230 PLWH were eligible (sites A: 11,271; B: 733; C: 1,344 PLWH), with > 75% in both the before and after periods. The ratio of alerts to responses was 11.9 at site A (2,245 alerts to 189 responses in 309 days; Fig 3A), and comparatively lower at sites B (756 alerts to 334 responses in 352 days, ratio=2.2; Fig 3B) and C (1,305 alerts to 896 responses in 246 days, ratio=1.5; Fig 3C). Responses to alerts were sporadic at sites A and B and consistent at site C. After the intervention, the proportion of PLWH with ≥ 1 visit stayed the same at site A (46% in both periods; p=0.47), decreased at site B (91% to 80%; p< 0.01), and increased at site C (72% to 81%; p< 0.01).

Figure 3. Alerts and responses over time in (A) Site A, (B) Site B, and (C) Site C

Conclusion

This pilot study was ecological by design: measures of retention in care were compared over two calendar periods, without accounting for changes in study populations, clinic characteristics, and policies in place over time (which could have impacted clinic attendance). Though engagement with the CDSS was suboptimal at some sites, this implementation pilot study has demonstrated the ability to implement a CDSS aimed at identifying at-risk PLWH, while highlighting areas for improvement in future larger scale studies.

Disclosures

Joel Wesley Thompson, MHS, PA-C, AAHIVS, DFAAPA, MHS, PA-C, AAHIVS, DFAAPA, Gilead (Shareholder, Speaker’s Bureau)Janssen (Speaker’s Bureau)Theratechnologies (Speaker’s Bureau)ViiV (Speaker’s Bureau) Tammeka Evans, MoP, ViiV Healthcare (Employee)

40. The Impact of Medically Assisted Therapy for Opiate Use Disorder in staphylococcus Aureus Bacteremia Patients Within a Large Hospital System - A Retrospective Cohort Study

Background

Intravenous drug use (IVDU) is a risk factor for development of S. aureus bacteremia (SAB) and prevalent in opiate use disorder (OUD). While the standard of care involves treating the underlying OUD with medically assisted therapy (MAT), it is unknown how much impact this has on clinical endpoints.

Methods

We conducted a retrospective cohort study of patients with IVDU with hospitalizations for SAB during a 28-month period from 9/2016 through 12/2018 in 10 urban and rural North Carolina hospitals in a single large health system. We compared outcomes for patients receiving prescription for MAT at discharge versus no MAT at discharge. MAT was defined as receiving methadone, buprenorphine, or naltrexone. Patients who expired inpatient were excluded from analysis. Clinical endpoints were 30- and 90-day mortality and 30-day SAB-related readmissions.

Results

Of the 174 patients, 28% received a prescription for MAT at discharge. The majority of the patients were Caucasian (88%), female (57%), with mean age of 37 years. Factors that significantly increased likelihood of MAT at discharge were female gender (34% vs 20%, p=0.04), having a complicated SAB (33% vs 28%, p=0.01), presence of a spinal/epidural abscess (57% vs 43%, p=0.002), and increased length of stay (LOS) (37 days vs 24 days, p=< 0.001). No difference in 30- and 90-day mortality was observed; only one patient in each group died within 90 days. Prescription for any MAT at discharge was associated with a significant decrease in the risk of SAB-related 30-day readmission (0% vs 17%, p=0.002).

Table 1: Baseline Characteristics

Table 2: MAT & Clinical Outcomes in S. aureus Bacteremia

Figure 1: Medically Assisted Therapy Prescribed at Discharge

Conclusion

Gender, more complicated infections, and prolonged LOS may increase the likelihood of receiving a prescription for MAT at discharge. MAT prescription at discharge may decrease the risk of 30-day SAB related readmission (NNT 5.9). The results suggest that provision of MAT to patients with SAB and history of IVDU should be incorporated into standardized treatment guidelines.

Disclosures

All Authors: No reported disclosures

A Big HIIT: A Fracture Dislocation of the Hip in a Young Man Participating in Extreme Conditioning Exercise: A Case Report

CASE

Hip dislocations with associated acetabular fracture are rare events usually associated with high-energy trauma. We describe an unusual case of low-energy acetabular fracture dislocation sustained by a 30-year-old athletic male athlete during a high-intensity training program.

CONCLUSION

Correct execution of training programs is important. Healthcare professionals as well as participants and instructors of extreme conditioning programs should be aware of this serious complication. Avoidance of this injury may be possible with increased interval recovery and improved technique.

Cryptococcus meningitis mimicking cerebral septic emboli, a case report series demonstrating injection drug use as a risk factor for development of disseminated disease

Background

Clinicians may be less inclined to consider a diagnosis of cryptococcal meningitis in people without HIV infection or transplant-related immunosuppression. This may lead to a delay in diagnosis particularly if disseminated cryptococcal disease mimics cerebral septic emboli in injection drug use (IDU) leading to a search for endocarditis or other infectious sources. Though, IDU has been described as a potential risk for disseminated cryptococcal disease.

Case presentations

We present two cases of cryptococcal meningitis in IDU without HIV or other obvious immune deficits. Both patients presented with at least 2 weeks of headache and blurred vision. They developed central nervous system (CNS) vasculitis, one of which mimicked septic cerebral emboli, but both resulted with poor neurologic outcomes.

Conclusions

IDU likely induces an underappreciated immune deficit and is a risk factor for developing cryptococcal meningitis. This diagnosis, which can mimic cerebral septic emboli through involvement of a CNS vasculitis, should be considered in the setting of IDU.

Pediatric bladder augmentation - Panacea or Pandora's box?

INTRODUCTION

Bladder augmentation is a surgery that can increase bladder capacity and compliance. The objective of this study was to provide a longitudinal review of pediatric bladder augmentation at a tertiary Canadian center.

METHODS

A retrospective review was performed on patients who underwent bladder augmentation at a tertiary pediatric hospital between 1986 and 2014. The primary objective was short- and long-term complications of augmentation. Secondary objectives were to review number of augmentation procedures performed over time and the utility of routine postoperative cystograms.

RESULTS

A total of 56 procedures were performed on 54 patients (28 males, 26 females) of mean age 10 years (standard deviation [SD] 5) and mean followup eight years (SD 5). The most common bowel segment used was ileum (87.5%). Twenty-eight patients (50%) received catheterizable channels. Overall complication rate was 15% and the most common complications were urinary tract infections (68.5%), worsening hydronephrosis (14.8%), bladder stone formation (14%), and hematuria (13%). In total, 19 of 54 (35.2%) patients returned to the operating room. The incidence of bladder perforation was 3.6%. Complications with the catheterizable channel occurred in 13 of 28 (46.4%), of which 10 were related to stomal stenosis. Forty patients had postoperative cystograms and extravasation was seen in three (7.5%). There was no malignancy during the followup. Only four augmentations were performed from 2008-2014.

CONCLUSIONS

Bladder augmentation likely represents a safe surgical treatment option. Extravasation on postoperative cystogram was uncommon and, thus, it may not be indicated routinely. The number of augmentation procedures performed has declined in recent years.

Electronic medical record alert activation increase hepatitis C and HIV screening rates in primary care practices within a large healthcare system

•

The electronic medical record alert improved screening for HCV and HIV.

•

91% of HCV and 100% of HIV positive patients were linked into care.

•

Low post-intervention screening rates suggest additional interventions are required.

Societal and economic burdens of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) continue to grow. The Centers for Disease Control and Prevention recommends a one-time HCV screen for individuals in the Baby Boomer population (those born between 1945 and 1965) and a one-time HIV screen for all individuals between ages 13–64 years regardless of risk factors, with more frequent screening for both conditions based on individual risk factors.

This study took place at Atrium Health, a healthcare system with approximately 12 million patient encounters per year. The aims of this study were to assess the impact of the HCV and HIV electronic medical record (EMR) alerts recently implemented on screening rates and linkage to care.

Data were collected from 12 primary care practices. Implementation of EMR alerts increased HCV and HIV screening from 1,934 of 59,632 (3.2%) to 13,726 of 60,422 (22.7%) and 6,950 of 112,813 (6.2%) to 12,379 of 109,173 (11.3%) respectively. The HCV screening resulted in an increase of patients with antibody positive results having a subsequent RNA test from 68% (122/179) to 98% (430/442). 74 of 81 (91%) of HCV and 15 of 15 (100%) of HIV positive patients were linked into care.

The addition of an EMR alert was associated with improved screening for HCV and HIV in primary care practices. Screening all patients decreases testing stigma since there is a lowered risk of disease transmission for those who test positive. However, post-intervention screening rates indicate further opportunities exist for additional interventions to increase screening rates.

Nutritional status of neurologically impaired children: Impact on comorbidity

BACKGROUND AND AIMS

Malnutrition is common in neurologically impaired (NI) children. It is, however, ill-defined and under-diagnosed. If not recognized and treated, it increases the burden of comorbidities and affects the quality of life of these children. The aim of this study was to characterize the nutritional status of a cohort of children followed up at a reference center for cerebral palsy (CP) in Brussels, Belgium, and to investigate possible links with the occurrence of comorbidities.

MATERIAL AND METHODS

We conducted a single-center retrospective study including all the children followed up at the Inter-university Reference Center for Cerebral Palsy ULB-VUB-ULg. The data were obtained by reviewing medical files. Anthropometric measurements as well as the etiology of neurological impairment, comorbidities, feeding patterns, and laboratory test results were collected. The children were assigned a nutritional diagnosis according to the World Health Organization and Waterlow definitions.

RESULTS

A total of 260 children with cerebral palsy were included, 148 males and 112 females. Their mean age was 10.9±4.3 years. The gross motor function classification system (GMFCS) level was I for 79 children, II for 63 children, III for 35 children, IV for 33 children, and V for 50 children. Of the children, 54% had a normal nutritional status, 34% showed malnutrition, and 8% were obese; 38% had oropharyngeal dysphagia. The sensitivity of mean upper arm circumference of<p10 to detect severe malnutrition was 95%. Specific growth charts for CP were neither sensitive nor specific for predicting the risk of comorbidities. Malnutrition was associated with an increased risk of comorbidities (relative risk of 2.4 [1.7; 3.4]). It was also associated with the occurrence of pneumonia, pressure ulcers, and pathological bone fracture.

DISCUSSION AND CONCLUSION

Children who are NI should be systematically and thoroughly screened for malnutrition, in the hope of offering early nutritional support and reduce comorbidities.

Computational modelling of forces acting on the femur in acetabular fractures: A finite element analysis study

BACKGROUND

The rising incidence of acetabular fractures in the elderly presents an increasing surgical challenge due to patient co-morbidities, complex fracture patterns' and osteoporotic bone. Of interest in this study are those of the quadrilateral plate, which are more common in elderly patients with osteoporosis. Following such injuries, the weight-bearing surface of the femoral head moves medially. Non-operative management of these fractures can lead to the acetabulum articulating on the femoral neck increasing the risk of subsequent femoral neck fracture as a result of the altered biomechanics.Using finite element analysis (FEA) this study seeks to understand the changing biomechanics of the proximal femur in such instances and to determine if there is a threshold of femoral head medialisation that can predict probability of femoral neck fracture.

METHODS

A femoral neck FEA model was created from the CT and MRI scans of a healthy hip. Using FEA, the model was used to apply point loading to the femoral head at the anatomical weight bearing area and subsequent lateralization of this point down to the femoral neck-shaft junction. This simulates the changing forces acting on the femur as the head medialises into a fractured acetabulum.

RESULTS

As the point of contact moved laterally the stress levels within the proximal femur increased steadily, particularly along the superior neck. Bending moment at the medial neck shaft junction also increased. This increase in stress levels can be seen as a corollary for risk of fracture within the femur.

CONCLUSION

With medialisation of the femur into a fractured acetabulum there is a significant change in the stress distribution within the femoral neck. Clinically, this is indicates that patients with such injuries are at an increased risk of femoral neck fractures once they begin to mobilise after the initial injury, a devastating result. This model may be of use to treating surgeons in predicting the risk of femoral neck fracture.

1276. Changes in Primary Care Pre-exposure Prophylaxis prescribing in a Large Healthcare System after the Implementation of an HIV Screening Alert and Educational Intervention

Background

The number of providers that prescribe pre-exposure prophylaxis (PrEP) for HIV remains low. Primary care providers (PCPs) are less knowledgeable than HIV providers (HIVPs) with regards to PrEP: fewer PCPs had heard of PrEP (76% vs. 98%), knew about prescribing PrEP (28% vs. 76%), or ever had prescribed it (17% vs. 64%). PCPs limited knowledge about PrEP and questions about insurance coverage were identified as barriers to prescribing PrEP. Additional information on changes in prescribing PrEP in primary care within a large healthcare system is limited.

Methods

12 practices were part of a systemwide implementation of an HIV screening Electronic Medical Record (EMR) alert in October 2017 for patients ages 18–64. The 12 primary care practices were also included as part of an educational intervention regarding HIV prevention presented in the first quarter of 2018. As part of the educational intervention, information on prescribing PrEP was included along with resources for linkage-to-care and insurance coverage. The number of PrEP prescriptions were summarized for all 12 practices one year prior to the EMR alert and one-year post-EMR alert. Paired T-test statistics were used to test the number of patients prescribed PrEP by each practice pre- and post-EMR alert. The same analysis was conducted one-year pre- and post- the educational intervention.

Results

Across the 12 practices, 62 PrEP prescriptions were written one year prior to the implementation of the EMR alert (M=5.2, SD=7.3) and 88 post-EMR alert (M=7.3, SD=6.4), a 42% increase (P = 0.02). There were no differences in PrEP prescriptions one-year pre- and post- the educational intervention (n = 69).

Conclusion

While the number of PrEP prescriptions written showed significant increase after the implementation of the EMR alert, the overall number of prescriptions in primary care are still relatively low. While there has been national attention to increase PrEP prescribing through initiatives with local health departments, efforts to increase PrEP uptake require additional interventions above and beyond education interventions to increase the knowledge, comfort, and skills of providers to prescribe PrEP.

Disclosures

All authors: No reported disclosures.

1085. Impact of a Novel Infectious Diseases Pharmacy Service on Medication-Related Errors and Linkage to Care in Inpatients Living with Human Immunodeficiency Virus

Background

Complexity of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) and lack of experience with treatment regimens by providers may lead to medication-related errors (MRE). Consequences of MRE may include loss of virologic suppression, development of ART resistance, HIV transmission, and increased morbidity and mortality. The purpose of this study was to compare ART-related MRE and linkage to care through consultation with Infectious Diseases (ID) providers as a result of ID-pharmacist review.

Methods

An ID pharmacist-led intervention incorporating prospective review of electronic medical records of adult patients admitted with an ICD-10 code for HIV was implemented. Patients not on ART were triaged for linkage to care with ID consultation, and those on ART received profile review to assess for and correct MRE. We then conducted an IRB-approved, quasi-experimental cohort study comparing adult patients living with HIV who were admitted between February 2017 to June 2017 (pre-intervention) and October 2018 to March 2019 (post-intervention). Patients on ART for indications other than the treatment of HIV were excluded. Rates of ART-related MRE and frequency of ID consultation with linkage to care were compared before and after our intervention.

Results

A total of 200 patients were included, with 100 patients in each of the intervention periods. The institutional stewardship program intervened to correct one error in the pre-intervention period, whereas 119 interventions were made in the post-intervention period with an acceptance rate of 97%. The proportion of patients who experienced an MRE decreased from 70% to 25% (absolute risk reduction 45%, P < 0.01). The total number of errors also decreased between intervention periods (102 vs. 36, P < 0.01). A description of ID pharmacist intervention type is provided in Figure 1. To link patients into care or clarify an ART regimen, the number of ID consults significantly increased from 19% to 39% (P < 0.01) as a result of the ID pharmacist-led initiative.

Conclusion

Focused ID pharmacy review of patients admitted with HIV and inpatient ART prescription as part of an antimicrobial stewardship program was successful in reducing ART-related MRE and increasing ID consultation to promote linkage to care.

Disclosures

All authors: No reported disclosures.

1325. Inpatient Initiation of ART Improves Short-Term Mortality in People Living with HIV

Background

Treatment of HIV is recommended as soon as possible and early initiation of combined antiretroviral therapy (cART) is associated with improved engagement in care; however, treatment with cART is often deferred in hospitalized patients despite being correlated with improved outcomes. We implemented an institutional intervention to ensure all people living with HIV (PLwH) were on cART during hospitalization to improve patient outcomes.

Methods

We prospectively identified all PLwH hospitalized at our institution and had ID physicians and pharmacists ensure they were on appropriate cART and linked to outpatient care. We retrospectively collected clinical and lab data to assess the impact of our intervention on inpatient mortality, 30-day mortality, 30-day readmission rate, and frequency of outpatient follow-up. Patients were excluded from analysis if they were admitted for hospice care.

Results

We identified 389 patient admissions in 275 unique patients, of which 304 admissions were already on cART at admission. After ID physician assessment, 37 of the 85 not on cART at admission were initiated on therapy. We assessed the impact of this intervention on short-term outcomes as listed in Table 1.

Despite the intervention group having similar immunologic and virologic baseline characteristics to those not initiated on cART, their inpatient and 30-day mortality was similar to those already on cART. Readmission rates also decreased in the intervention group. Thirteen of 24 patients in the intervention group who could be tracked for long-term follow-up within our system achieved virologic suppression by 90 days after hospital discharge.

Conclusion

Inpatient treatment with cART during hospitalization improves short-term mortality outcomes. This study also demonstrates the value of inpatient cART treatment as most patients achieved virologic suppression at subsequent outpatient follow-up.

Disclosures

All authors: No reported disclosures.

Does Google™ Have the Answers? The Internet-based Information on Pelvic and Acetabular Fractures

Introduction

The aim of this study is to assess the readability and reliability of internet-based information on pelvic and acetabular fractures.

Methods

The three most popular English-based internet search engines are Google, Yahoo, and Bing. Quality was assessed using the DISCERN tool, the Journal of the American Medical Association tool, and the presence of the Health on the Net Code (HONcode) seal. Readability was assessed using a combination of the Flesch Reading Ease Score and the Flesch-Kincaid grade level. Inclusion criteria included English language websites with the relevant search terms. We excluded videos, YouTube links, or sponsored advertisements. Search terms included acetabular fracture/fractured acetabulum and pelvic fracture/fractured pelvis. The top 25 websites in each search engine were reviewed. The searches for acetabular fractures and pelvic fractures generated 75 websites in total. Duplicates were excluded.

Results

The search for acetabular fracture revealed 36 discrete websites among the three search engines, and the search for pelvic fractures revealed 45 websites. Overall, the average reading grade was 9.7 for acetabular websites and 13.6 for pelvis websites. The quality of the websites was poor across all key performance indicators studied.

Conclusion

Physicians should be aware of the quality of medical information available to patients via internet searches because physicians should play a central role in the navigation of poor quality information to help direct patient-centered care.

A novel approach using 3-D printing in the Irish National Centre for pelvic and acetabular surgery

BACKGROUND

Complex pelvic fractures present the orthopaedic surgeon with many challenges. 3-D printed models may provide assistance in pre-operative planning, may lead to improvements in intra-operative (i) decision making and (ii) efficiencies (time reduction, blood loss reduction, screening reduction) and may result in improvements in post-operative outcomes (fracture reduction & quality of life). The models also provide hands-on opportunities for orthopaedic trainees and patients. This may result in improvements in (i) education/training regarding the management of pelvic and acetabular fractures for orthopaedic trainees and (ii) improvements in patient consenting and overall patient satisfaction.

DESIGN

Single-centre, two orthopaedic surgeons (pelvic and acetabular fellowship trained), prospective observational study. Twenty patients with acute displaced pelvic/acetabular fracture(s); ten 3-D-printed pelvis and ten non-printed cases for comparison. The comparison cohorts were matched for fracture classification, sex and age.

OUTCOME MEASURES

Classification assistance, intra-operative time, estimated blood loss, screening amount, post-operative reduction and infection, EQ-5D-5L, teaching/educational assistance and pre-operative counselling.

RESULTS

The models provided more information regarding fracture pattern, however, this did not result in change of CT-planned approach/procedure or patient outcomes. The models scored highly on surgeon's questionnaire. The models were found to have a positive impact on trainee education and patient consenting/counselling. With regard to objective comparisons, there was no significant improvements in time-to-surgery, intra-operative time, estimated blood loss, screening amount, fracture reduction or infection rate. There was no significant difference in quality of life questionnaire ~ 12 months post-surgery (statistical tests used; Cohen's effect size and Fisher's exact test).

CONCLUSIONS

Whilst the authors recognize the positive subjective findings with respect to the use of 3-D printing in pelvic and acetabular trauma in our National Centre, objective findings were lacking.

Where does Pelvic and Acetabular Fracture Treatment fit into the Newly Proposed Major Trauma Model in Ireland?

Aim To provide the most up to date reference of referral patterns for pelvis and acetabular (PA) fractures in Ireland and discuss where services should ideally be located. Methods A retrospective review was conducted of all referrals to the national referral centre for PA fractures in Ireland for 2016 and 2017. Results Over the two-year study period 456 referrals were made. Mean age of patients was 53 years, 62.9% were male. Management was conservative in 60.7%, operative in 38.2% while 1.1% died prior to transfer. Nearly half of fractures (47.8%) were due to falls with 38.6% due to road trauma. Referrals from the proposed central trauma network accounted for 76.1% of referrals. Median length of stay was 7 days. Average cost of operative treatment was €11,774. Conclusions PA trauma is associated with significant morbidity and costs to both patients and society. Consideration needs to be given to where best to place PA services to ensure the highest quality care in this cohort of patients

Major histocompatibility complex class I in the horse (Equus caballus) placenta during pregnancy and parturition

BACKGROUND

Major histocompatibility protein class I (MHC-I) is believed to be expressed in the horse allantochorion only in limited areas at limited times. However, its expression has only been investigated in early pregnancy with non-quantitative techniques that cannot reliably detect small amounts of protein.

OBJECTIVE

To quantify the relative expression of MHC-I in the allantochorion and endometrium during days 90-240 of pregnancy (PREG), parturition with physiological delivery of fetal membranes (PHYS), and parturition with retention of these membranes (FMR). Also, to visualize protein expression and determine whether classical or non-classical MHC-I mRNA is expressed.

ANIMALS

Heavy draft horses.

SETTING

PREG horses (n = 12) were sampled postmortem at a slaughterhouse. PHYS (n = 6) and FMR (n = 5) horses were sampled at farms in the vicinity of Olsztyn, Poland.

METHODS

For relative quantification of MHC-I, western blotting with densitometry was used. To visualize MHC-I, immunohistochemistry was used. For mRNA identification, RT-PCR was performed.

RESULTS

Although the quantity of MHC-I was lower during PREG than parturition, it was present in the allantochorion and endometrium during PREG. During parturition, MHC-I expression was upregulated in the allantochorion (PHYS vs. PREG: 2.7-times higher, 95% confidence interval, 1.3- to 5.7-times higher; FMR vs. PREG: 3.2-times higher, 95% confidence interval, 1.5- to 6.7-times higher). At parturition, staining for MHC-I was detected in the microcotyledons. Classical and non-classical MHC-I were expressed in both tissues during PREG, PHYS, and FMR.

CONCLUSION

MHC-I protein is present in the horse allantochorion and endometrium for at least the first two-thirds of pregnancy and at parturition.

The Improvement Readiness scale of the SCORE survey: a metric to assess capacity for quality improvement in healthcare

BACKGROUND

Quality improvement efforts are inextricably linked to the readiness of healthcare workers to take them on. The current study aims to clarify the nature and measurement of Improvement Readiness (IR) by 1) examining the psychometric properties of a novel IR scale, 2) assessing relationships between IR and other safety culture domains 3) exploring whether IR differs by healthcare worker demographic factors, and 4) examining linguistic differences in word type use between high and low scoring IR work settings from their free text responses.

METHODS

Of 13,040 eligible healthcare workers across a large academic health system, 10,627 (response rate 81%) completed the 5-item IR scale, demographics, safety culture scales, and two open-ended questions. Psychometric analyses, correlations and ANOVAs tested the properties of IR. Linguistic Inquiry Word Count software assessed comments from open-ended questions.

RESULTS

The IR scale exhibited strong psychometric properties and a one factor model fit the data well (Cronbach's alpha = .93; RMSEA = .07; CFI = 99; TLI = .99). IR scores differed significantly by role, shift, shift length, and years in specialty. IR correlated significantly and in expected directions with safety culture scales. Linguistic analyses revealed that people in low versus high IR work settings used significantly more words in their responses, and specifically more past tense verbs (e.g., "ignored"), negative emotion words (e.g., "upset"), and first person singular ("I"). Workers from high IR work settings used significantly more positive emotions words (e.g., "grateful") and social words (e.g., "team").

CONCLUSION

The IR scale exhibits strong psychometric properties, is associated with better safety and teamwork climate, lower burnout, and predicts linguistic differences in high versus low IR groups.