Involving patients in drug development for Neglected Tropical Diseases (NTDs): A qualitative study exploring and incorporating preferences of patients with cutaneous leishmaniasis into Target Product Profile development

BACKGROUND

Target Product Profiles (TPPs) are instrumental to help optimise the design and development of therapeutics, vaccines, and diagnostics - these products, in order to achieve the intended impact, should be aligned with users' preferences and needs. However, patients are rarely involved as key stakeholders in building a TPP.

METHODOLOGY

Thirty-three cutaneous leishmaniasis (CL) patients from Brazil, Colombia, and Austria, infected with New-World Leishmania species, were recruited using a maximum variation approach along geographic, sociodemographic and clinical criteria. Semi-structured interviews were conducted in the respective patient's mother tongue. Transcripts, translated into English, were analysed using a framework approach. We matched disease experiences, preferences, and expectations of CL patients to a TPP developed by DNDi (Drug for Neglected Diseases initiative) for CL treatment.

PRINCIPAL FINDINGS

Patients' preferences regarding treatments ranged from specific efficacy and safety endpoints to direct and significant indirect costs. Respondents expressed views about trade-offs between efficacy and experienced discomfort/adverse events caused by treatment. Reasons for non-compliance, such as adverse events or geographical and availability barriers, were discussed. Considerations related to accessibility and affordability were relevant from the patients' perspective.

CONCLUSIONS/SIGNIFICANCE

NTDs affect disadvantaged populations, often with little access to health systems. Engaging patients in designing adapted therapies could significantly contribute to the suitability of an intervention to a specific context and to compliance, by tailoring the product to the end-users' needs. This exploratory study identified preferences in a broad international patient spectrum. It provides methodological guidance on how patients can be meaningfully involved as stakeholders in the construction of a TPP of therapeutics for NTDs. CL is used as an exemplar, but the approach can be adapted for other NTDs.

Complete field-induced spectral response of the spin-1/2 triangular-lattice antiferromagnet CsYbSe2

Fifty years after Anderson's resonating valence-bond proposal, the spin-1/2 triangular-lattice Heisenberg antiferromagnet (TLHAF) remains the ultimate platform to explore highly entangled quantum spin states in proximity to magnetic order. Yb-based delafossites are ideal candidate TLHAF materials, which allow experimental access to the full range of applied in-plane magnetic fields. We perform a systematic neutron scattering study of CsYbSe2, first proving the Heisenberg character of the interactions and quantifying the second-neighbor coupling. We then measure the complex evolution of the excitation spectrum, finding extensive continuum features near the 120°-ordered state, throughout the 1/3-magnetization plateau and beyond this up to saturation. We perform cylinder matrix-product-state (MPS) calculations to obtain an unbiased numerical benchmark for the TLHAF and spectacular agreement with the experimental spectra. The measured and calculated longitudinal spectral functions reflect the role of multi-magnon bound and scattering states. These results provide valuable insight into unconventional field-induced spin excitations in frustrated quantum materials.

Glycopeptide Antibiotics Impair Neutrophil Effector Functions

INTRODUCTION

Neutrophilic granulocytes represent the first line of defense against microorganisms. Granulocytes phagocytose microorganisms and specifically synthesize oxygen radicals against them, which eventually kills the invaders.

METHODS

Neutrophilic granulocytes were isolated from peripheral blood of healthy volunteer donors. Putative interference of new-generation antibiotics with neutrophil function was tested using a collection of granulocyte-stimulating agents and Amplex™ Red-based plate assay and flow cytometry-based respiratory burst assays. In addition, phagocytosis of E. coli, IL-8 production, bactericidal activity, and CD62L expression of granulocytes were evaluated.

RESULTS

Of note, we found that the two glycopeptide antibiotics dalbavancin and teicoplanin inhibited ROS production upon granulocyte activation via different signaling pathways in a dose-dependent manner. Dalbavancin also blocked the PMA-induced shedding of CD62L. In contrast, the oxazolidinone antibiotics tedizolid and linezolid had no effect on neutrophil function, while the combination of ceftazidime/avibactam dose dependently inhibited the fMLP/Cytochalasin B-induced granulocyte burst in a dose-dependent manner. Additionally, we showed that dalbavancin and teicoplanin as well as sulfametrole/trimethoprim and ceftazidime/avibactam inhibited baseline and PMA-induced IL-8 production by neutrophilic granulocytes. Moreover, dalbavancin impaired the bactericidal activity of neutrophilic granulocytes.

CONCLUSION

We here identified hitherto unknown inhibitory effects of several classes of antibiotics on the effector functions of neutrophilic granulocytes.

Ventilation with the esophageal-tracheal Combitube during general anaesthesia: assessing complications in 540 patients

Background

The esophageal-tracheal Combitube (ETC) was developed for the management of difficult airways but can also be used for general anaesthesia.

Methods

This clinical study collected data from patients undergoing anaesthesia with the ETC in order to assess the rate of complications.

Results

Five hundred forty patients were ventilated with the ETC. In 94.8% (512/540), insertion was performed for the first time by the respective physician. The following minor complications were observed: 38.7% sore throat, 30.9% blood on tube as sign of mucosal lesions and 17.0% cyanotic tongue. Experience decreased the risk of mucosal lesions (odds ratio [OR]: 2.3, 95% confidence interval [CI]: 1.5-3.5). A higher than recommended volume of the oropharyngeal cuff was associated with blood on the ETC (OR: 1.5, 95% CI: 1.0-2.3) and tongue cyanosis (OR: 2.3, 95% CI: 1.4-3.7). Ventilation for more than 2 h was associated with tongue cyanosis (OR: 2.2, 95% CI: 1.6-3.1) and tongue protrusion (OR: 1.4, 95% CI: 1.1-1.9).

Conclusion

We conclude that the Combitube may be used for short procedures requiring general anaesthesia, but the high rate of minor complications limits its value when other alternatives such as a laryngeal mask airway are available. The tested method appears safe regarding major complications, but minor complications are common. Adherence to recommended cuff volumes, experience with the ETC and limiting its use to surgeries lasting less than 2 h might reduce the rate of complications.

Influence of Acute and Chronic Graft-Versus-Host Disease on Persistence of Antibodies against Measles, Mumps, Rubella and Varicella in the First Year after Autologous or Allogeneic Hematopoietic Stem Cell Transplantation

Patients after hematopoietic stem cell transplantation (HSCT) are vulnerable to infections due to severe immunosuppression. Live-attenuated vaccines are contraindicated for two years after HSCT. The aim of this study was to assess the persistence of antibodies against measles, mumps, rubella and varicella in the first year after HSCT. Forty patients undergoing autologous (n = 12) or allogeneic (n = 28) HSCT were included in this study. Specific IgG antibodies to measles, mumps, rubella and varicella virus in serum samples were assessed by the LIAISON XL, a fully automated chemiluminescence analyzer, at seven different time points starting one week before HSCT and up to 12 months after HSCT. At baseline, before HSCT, most patients showed antibodies against measles (100%), mumps (80%), rubella (97.5%) and varicella (92.5%). Although titers declined over time, most patients retained antibodies against measles (92.5%), mumps (62.5%), rubella (87.5%) and varicella (85%) up to 12 months after HSCT. There was no significant difference between patients with and without GvHD concerning persistence of antibody titers. Significantly higher varicella titers were detected in autologous patients compared to patients with chronic GvHD. Considering that live-attenuated vaccines should not be administered during the first year after HSCT, the persistence of antibodies against these diseases is relevant.

488 TULA for Bladder Tumours in a University Teaching Hospital: Outcomes Over a 2-Year Period

Aim

TULA (Transurethral laser ablation) of bladder tumours is a relatively non-invasive procedure that is carried out on a day-case basis under local anaesthesia, providing an attractive option for treating recurrent non-muscle invasive bladder cancer (NMIBC). However, data describing efficacy rates are limited.

Method

We carried out a retrospective audit of all TULA procedures carried out for bladder lesions between January 2018 and December 2019. Patients were identified using clinical coding and data collected using electronic case note data. Analysis was performed using Microsoft Excel.

Results

48 patients were identified, 75% were male and the average age was 77. Performance status (PS) was formally documented in 6 patients, with a median of 2.5. A total of 77 TULA procedures were identified. 7 patients had TULA as primary treatment, all but one of these patients had significant co-morbidities.

Biopsies were taken in 83% of procedures. Recurrence rate at 3 months was 29% (n=14). 18% (n=8) of patients went on to have repeat TULA and the remainder went on to have TURBT or biopsy and cystodiathermy. Of those patients with recurrence, 18% had disease progression. 1 patient required catheterisation and irrigation overnight, all other patients were discharged the same day. No patients required re-admission.

Conclusions

TULA is a safe, well tolerated procedure to treat low-grade, recurrent bladder tumours. It can also be used as a palliative procedure for high-grade lesions in patients with multiple co-morbidities. Future work includes collection of objective data on tolerance in the form of VAS pain scoring.

Magic Gap Ratio for Optimally Robust Fermionic Condensation and Its Implications for High-T_{c} Superconductivity

Bardeen-Schrieffer-Cooper (BCS) and Bose-Einstein condensation (BEC) occur at opposite limits of a continuum of pairing interaction strength between fermions. A crossover between these limits is readily observed in a cold atomic Fermi gas. Whether it occurs in other systems such as the high temperature superconducting cuprates has remained an open question. We uncover here unambiguous evidence for a BCS-BEC crossover in the cuprates by identifying a universal magic gap ratio 2Δ/k_{B}T_{c}≈6.5 (where Δ is the pairing gap and T_{c} is the transition temperature) at which paired fermion condensates become optimally robust. At this gap ratio, corresponding to the unitary point in a cold atomic Fermi gas, the measured condensate fraction N_{0} and the height of the jump δγ(T_{c}) in the coefficient γ of the fermionic specific heat at T_{c} are strongly peaked. In the cuprates, δγ(T_{c}) is peaked at this gap ratio when Δ corresponds to the antinodal spectroscopic gap, thus reinforcing its interpretation as the pairing gap. We find the peak in δγ(T_{c}) also to coincide with a normal state maximum in γ, which is indicative of a pairing fluctuation pseudogap above T_{c}.

AB1209 MECHANISTIC FACTORS CONTRIBUTING TO PAIN AND FATIGUE IN FIBROMYALGIA AND ME/CFS: AUTONOMIC AND INFLAMMATORY INSIGHTS FROM AN EXPERIMENTAL MEDICINE STUDY

Background

Fibromyalgia and ME/CFS are multifaceted conditions with overlapping symptoms(1); the pathoaetiological mechanisms are complex and debated(2), however there is a strong association with features of hereditary disorders of connective tissue (hypermobility) and autonomic and inflammatory abnormalities (1,2).

Objectives

To determine potential autonomic and inflammatory mechanisms of pain and fatigue in fibromyalgia and ME/CFS

Methods

After excluding participants with WCC higher than 10 (suggesting acute infection) baseline markers of inflammation (CRP and ESR) were available for 60 patients with confirmed diagnoses of Fibromyalgia and/ or ME/CFS and 23 matched controls. Participants then underwent full research diagnostic evaluation including a hypermobility assessment(1) and autonomic challenge (60 degree head up tilt, ISRCTN78820481). Subjective pain and fatigue were assessed before and after challenge (VAS). Linear regression models were used to explore predictors, with adjustment for confounders as appropriate. Mediation analyses (looking for mechanistic effects) were conducted according to the method of Hayes (3) and mediation considered significant if bootstrapped confidence intervals of the estimated indirect effect did not cross zero. In these mediation analyses predictor variable was group membership (patient or control), outcome variable was change in 1)pain and 2)fatigue induced by challenge and mediatiors 1)no of connective tissue features in hypermobility diagnostic criteria endorsed by participant; 2)baseline inflammatory markers.

Results

ESR and CRP were significantly higher in patients rather than controls, even after correcting for BMI, age and sex (B=5.15, t=2.05, p=0.044; B=1.77, t=2.15, p=0.044 respectively). Adjusted ESR and CRP correlated with both subjective fatigue (B=0.44, t=2.09, p=0.04; B=1.63, t=2.60, p=0.011) and pain severity (B=0.13, t=2.51, p=0.014; B=0.45, t=3.01, p=0.004) at baseline. Autonomic challenge amplified pain (B=14.20, t=2.87, p=0.005) and fatigue (B=31.48, t=5.95, p=<0.001) in patients to a significantly greater degree than controls, controlling for baseline levels. Baseline ESR and CRP also predicted challenge-induced increase in fatigue (B=0.78, t=370, p=<0.001; B=1.91, t=3.36, p=<0.001) and ESR challenge-induced increases in pain (B=0.46, t=2.35, p=0.021).

Mediation analysis demonstrated that number of connective tissue features expressed in hypermobility criteria mediated the degree to which subjective pain was increased by the autonomic challenge (Bootstraped 95% CI of indirect effect do not cross zero, 0.1572 – 6.8171). ESR mediated the degree to which subjective fatigue was increased by the autonomic challenge (Bootstraped 95% CI of indirect effect do not cross zero,0.7541 – 7.3888).

Conclusion

To our knowledge this is the first study to directly explore autonomic and inflammatory mechanisms of pain and fatigue in a combined population of Fibromyalgia and ME/CFS. This study this adds to the evidence-base of baseline inflammatory abnormalities in fibromyalgia and ME/CFS. It highlights their potential role in predicting symptom severity and their potential mechanistic role in autonomic induced pain and fatigue, suggesting future treatment strategies.

References

[1]Eccles JA, Thompson B, Themelis K, Amato ML, Stocks R, Pound A, et al. Beyond bones: The relevance of variants of connective tissue (hypermobility) to fibromyalgia, ME/CFS and controversies surrounding diagnostic classification: an observational study. Clin Med (Lond). 2021;21(1):53-8.

[2]Eccles JA, Davies KA. The challenges of chronic pain and fatigue. Clin Med (Lond). 2021;21(1):19-27.

[3]Hayes AF. Partial, conditional, and moderated moderated mediation: Quantification, inference, and interpretation. Commun Monogr. 2018;85(1):4-40.

Disclosure of Interests

Jessica Eccles: None declared, Charlotte Thompson: None declared, Beth Thompson: None declared, Marisa Amato: None declared, Kristy Themelis: None declared, Hugo Critchley: None declared, Neil Harrison Grant/research support from: speakers bureau, Kevin Davies: None declared

Vaccine Response in the Immunocompromised Patient with Focus on Cellular Immunity

During the last few years, we have experienced a shift in how we evaluate the effectiveness of vaccines [...]

Tick-Borne Encephalitis Specific Lymphocyte Response after Allogeneic Hematopoietic Stem Cell Transplantation Predicts Humoral Immunity after Vaccination

The aim of this prospective study was to assess lymphocyte proliferative and cytokine response prior to and following tick-borne encephalitis (TBE) immunization among patients after allogeneic hematopoietic stem cell transplantation (HSCT). Seventeen adult patients 11–13 months after HSCT and eight unvaccinated healthy adults received up to three TBE vaccinations. Following in vitro stimulation with TBE-antigen, lymphocyte proliferation and cytokine secretion (IL-2, IL-10, IL-13, TNF-alpha, IFN-gamma, GM-CSF) were analyzed by thymidine incorporation assay and the Luminex system. Ten patients (59%) showed significant baseline TBE-specific lymphocyte proliferation (stimulation index (SI) > 3) prior to vaccination, but none of the unvaccinated controls (p = 0.002). All patients with a TBE-specific antibody response after two vaccinations (at least 2-fold increase of neutralization test titers) exhibited a strong TBE-specific lymphocyte proliferative response at baseline (SI > 10). Patients with sibling donors had a significantly stronger baseline TBE-specific lymphocyte proliferative and IL-13 cytokine response than patients with unrelated donors (p < 0.05). In conclusion, a relevant proportion of patients showed TBE-specific lymphocyte proliferative and cytokine responses prior to vaccination after HSCT, which predicted the humoral response to the vaccine. Patients with vaccinated sibling donors were more likely to elicit a cellular immune response than patients with unrelated donors of unknown vaccination status.

The role of interoception in the mechanism of pain and fatigue in fibromyalgia and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)

Introduction

Pain, fatigue and anxiety are common features of fibromyalgia and ME/CFS and significantly impact quality of life. Aetiology is poorly defined but dysfunctional inflammatory, autonomic and interoceptive (sensing of internal bodily signals) processes are implicated.

Objectives

To investigate how altered interoception relates to baseline expression of pain, fatigue and anxiety symptoms in fibromyalgia and ME/CFS and in response to an inflammatory challenge.

Methods

Sixty-five patients with fibromyalgia and/or ME/CFS diagnosis and 26 matched controls underwent baseline assessment: pressure-pain thresholds and self-report questionnaires assessing pain, fatigue and anxiety severity. Participants received injections of typhoid (inflammatory challenge) or saline (placebo) in a randomised, double-blind, crossover design, before completing heartbeat tracking tasks. Three interoception dimensions were examined: subjective sensibility, objective accuracy and metacognitive awareness. Interoceptive trait prediction error was calculated as discrepancy between accuracy and sensibility.

Results

Patients with fibromyalgia and ME/CFS had significantly higher interoceptive sensibility and trait prediction error, despite no differences in interoceptive accuracy. Interoceptive sensibility and trait prediction error correlated with all self-report pain, fatigue and anxiety measures, and with lower pain thresholds. Anxiety mediated the positive-predictive relationships between pain (Visual Analogue Scale and Widespread Pain Index), fatigue impact and interoceptive sensibility. After inflammatory challenge, metacognitive awareness correlated with baseline self-reported symptom measures and lower pain thresholds.

Conclusions

This is the first study investigating interoceptive dimensions in patients with fibromyalgia and ME/CFS, which were found to be dysregulated and differentially influenced by inflammatory mechanisms. Interoceptive processes may represent a new potential target for diagnostic and therapeutic investigation in these poorly understood conditions.

Disclosure

No significant relationships.

Extraction of Beam-Spin Asymmetries from the Hard Exclusive π^{+} Channel off Protons in a Wide Range of Kinematics

We have measured beam-spin asymmetries to extract the sinϕ moment A_{LU}^{sinϕ} from the hard exclusive e[over →]p→e^{'}nπ^{+} reaction above the resonance region, for the first time with nearly full coverage from forward to backward angles in the center of mass. The A_{LU}^{sinϕ} moment has been measured up to 6.6  GeV^{2} in -t, covering the kinematic regimes of generalized parton distributions (GPD) and baryon-to-meson transition distribution amplitudes (TDA) at the same time. The experimental results in very forward kinematics demonstrate the sensitivity to chiral-odd and chiral-even GPDs. In very backward kinematics where the TDA framework is applicable, we found A_{LU}^{sinϕ} to be negative, while a sign change was observed near 90° in the center of mass. The unique results presented in this Letter will provide critical constraints to establish reaction mechanisms that can help to further develop the GPD and TDA frameworks.

AB0949 AUTONOMIC AND INFLAMMATORY MECHANISMS OF PAIN AND FATIGUE IN FIBROMYALGIA AND ME/CFS: AN INTERVENTIONAL STUDY

Background:

Fibromyalgia and ME/CFS are complex disorders with overlapping symptoms; the pathoaetiology and clinical distinction are debated, however inflammatory and autonomic abnormalities are observed.

Objectives:

To investigate the role of inflammatory and autonomic nervous system responses in mechanisms of pain and fatigue in fibromyalgia and ME/CFS

Methods:

63 patient participants with clinical diagnoses of fibromyalgia and/or ME/CFS were recruited into a multi-stage interventional study (ISRCTN78820481) alongside 24 healthy controls. All underwent research diagnostic criteria evaluation. The majority underwent autonomic challenge (60 degree head up tilt) and/or inflammatory challenge (placebo-controlled typhoid vaccination) with baseline characterisation of symptoms, inflammatory markers and pre-post measures of pain and fatigue.

Results:

Of the 63 patients, 32% of patients had received a clinical diagnosis of Fibromyalgia; 38% ME/CFS and 30% dual diagnoses. Following research evaluation 89% met ACR diagnostic criteria for fibromyalgia; 94% Canadian Criteria for ME/CFS; 97% Fukada Criteria for ME/CFS

There was a significantly higher ESR in patients compared to controls (p= 0.036). There was a trend towards higher CRP in patients compared to controls (p= 0.076).

ESR correlated with baseline pain score (r=0.309, p=0.011), fatigue severity (r=0.262, p=0.032), fatigue impact (r=0.382, p=0.014) change in fatigue score induced by tilt (r=0.319, p=0.011) and change in pain score induced by placebo-controlled inflammation (r=-0.279, p=0.043). Similarly CRP level correlated with baseline pain score (r=0.340, p=0.005), fatigue impact (r=0.439, p=0.004), change in fatigue (r=-0.277, p=0.045) and pain score (r=-0.394, p=0.014) induced by placebo-controlled inflammation and change in pressure pain theshold induced by tilt (r=0.286, p=0.027).

Baseline IL6 was higher in patients than controls (p = 0.002), correlating with baseline pain score (r = 0.345, p = 0.002) and change in pain score induced by tilt (r=0.281, p=0.21). Change in IL6 induced by inflammatory challenge correlated with inflammation induced fatigue score (r = 0.378, p = 0.01).

Conclusion:

Inflammatory and autonomic mechanisms contribute to pain and fatigue in this frequently overlooked patient group, highlighting possibilities for targeted treatments. Such data will be enriched going forward by neuroimaging and transcriptomic insights.

References:

n/a

Acknowledgments:

This work was supported by Versus Arthritis, Action for Me, Fibroduck Foundation and NIHR

Disclosure of Interests:

Jessica Eccles: None declared, Marisa Amato: None declared, Charlotte Thompson: None declared, Kristy Themelis: None declared, Hugo Critchley: None declared, Neil Harrison Grant/research support from: Yes, Speakers bureau: Yes, Kevin Davies: None declared

Abstract TP370: Role of Stroke Coordinators in Improving Post-Operative Nursing Care for Patients Undergoing Carotid Revascularization Procedures

Background: The Joint Commission (TJC) mandates standardized post-operative care for Carotid Artery Stenting (CAS) and Carotid Endarterectomy (CEA). We designed and implemented a standardized and evidence-based medical power plan (MPP).

Purpose: To address low early utilization of the MPP, stroke coordinators designed and implemented a Quality Improvement (QI) project to: 1) Monitor and improve MPP utilization for CAS/CEA patients in all applicable nursing units, 2) track cases of non-compliance, and 3) determine causes of non-compliance and establish a feed-back loop for staff.

Methods: Designed in coordination with neurologists, neurosurgeons, and cardiologists; the MPP was implemented in Jan 2016. We monitored MPP order rates and nursing compliance for MPP components such as post-procedure neuro-assessments. An education intervention for post-CEA/CAS nursing care, including NIHSS certification, was provided to nurses across applicable units. Residents and fellows were re-educated on ordering the MPP. Three PDSA cycles were completed. Nursing compliance was shared with leadership and feedback was provided to nursing staff.

Result: A total of 281 procedures were completed from January 2016 - June 2019. The first quarter (Q1) MPP order rate was 73% and nursing compliance for documenting a neurological assessment was 45%. Each PDSA cycle (Figure 1) was associated with an increase in the MPP order rate. For the years 2017-2019 an order rate of 81%, 85%, and 100% was observed respectively. Nursing compliance with neuro-assessment documentation also demonstrated an annual increase across the same time period (68%, 72% and 97%). The tests for trend in annual ordering and compliance rates were statistically significant (p value for both < 0.01).

Conclusion: Stroke coordinators play a vital role in improving practice standards and guideline implementation. Stroke coordinator oversight in CAS/ CEA cases positively impacted the MPP order rate and nursing compliance.

Abstract WP358: Comprehensive Integrated Stroke System: A Novel Approach to Optimizing Cerebrovascular Disease Care

Introduction: There is a need to deliver endovascular stroke therapy (EST) locally and rapidly, due to the time sensitivity of acute ischemic stroke (AIS). However, the optimal distribution of resources, and means to maintain quality outcomes in patients with diseases that benefit from concentrated care at specialized centers, including subarachnoid hemorrhage (SAH), is unknown.

Methods: We performed a multicenter, observational cohort study across our 11-hospital network from Jan 2017 - Feb 2019, identifying AIS patients who received EST. From Jan 2017 - Aug 2017, there was one CSC in the system. Starting in Aug 2017, we implemented an Integrated Stroke System (ISS), in which 3 additional centers became CSCs, practices were standardized across a single physician group covering all 4 CSCs, and SAH care was centered at the original CSC, while EST was performed at 3 new CSCs. Logistic regression adjusted for age, sex, NIHSS, direct vs. transfer arrival, and time from onset to recanalization was used to assess likelihood of good outcome, defined as discharge to home or rehabilitation. Results are given as median [IQR] and OR [95% CI].

Results: Among 478 patients who received EST, median age was 68 [57-78], 47% were female, and 37% were white. Over the course of the study (Fig. 1), the number of monthly EST cases increased; EST volume at our original CSC remained stable, and an increasing EST was performed at the new CSCs (p<0.01). Monthly SAH case volume remained unchanged at the original CSC (29 cases vs. 30 cases, p=0.68). After implementation of our ISS, there was a decrease in the time from arrival to groin puncture (107 min [88-125] vs 92 min [67-120]; p<0.01). Among patients presenting 0-6 hours, there was a significant improvement in likelihood of good outcome after ISS (OR 2.59 [1.06-6.35]; p<0.05).

Conclusions: By restructuring our stroke system of care and extending EST capability, we observed increased EST utilization and improvement in quality of care for AIS patients.

Abstract TMP10: Real-World Analysis of Endovascular Stroke Therapy Outcomes for Patients With Large Vessel Occlusions After Inter-Hospital Transfer

Introduction: Prior studies suggest that patients with large vessel occlusion (LVO) who undergo endovascular stroke therapy (EST) after inter-hospital transfer (IHT) have worse outcomes than those who present directly to EST centers. However, these studies were largely derived from clinical trials or registries and may not be representative of real-world clinical practice.

Methods: We performed a multicenter, observational cohort study on acute ischemic stroke (AIS) patients with LVO that presented to EST-capable centers directly (LVO-D) or after IHT (LVO-T) between 1/1/2018 to 2/1/2019. The study included 11 hospitals in the Houston area, of which 4 are EST-capable. Clinical data were collected using our cerebrovascular data registry. All transfers were from non-EST capable hospitals to EST-capable hospitals. Logistic regression adjusted for age, NIHSS, occlusion location and direct vs transfer arrival was used to assess the likelihood of good outcome, defined as discharge to home or rehabilitation. Results are given as median [IQR] and OR [95% CI].

Results: Among 4,313 patients with AIS, 772 (18%) patients had LVO. Among LVO patients, median age was 68 [59-79], 47% were female, 51% were white, 378 (49%) were LVO-D and 394 (51%) were LVO-T. Median IHT time was 152 min [114-198]. LVO-D patients arrived at EST-treating hospitals with superior ASPECTS compared to LVO-T (9 [7-10] vs 7 [6-9], p<0.0001), but comparable CTP RAPID infarct cores (5 mL [0-31] vs 7 mL [0-38], p=0.59). LVO-D and LVO-T patients were just as likely to have ICA occlusions (13% vs 12%; p=.64) and proceeded to have equivalent rates of EST (43% vs 47%, p=0.95). Among LVO patients who did not receive EST, good discharge outcomes were comparable (34% vs. 35%, p=0.66, LVO-D vs. LVO-T). Good discharge outcomes were also similar for those receiving EST (34% vs. 37%, p=0.57, LVO-D vs. LVO-T). In logistic regression adjusted for age, NIHSS, and occlusion location, likelihood of good discharge outcome was comparable between the two groups (OR 0.98 [0.71-1.36]).

Conclusion: In this real-world cohort of a multi-center stroke network, IHT was not associated with worse outcomes for patients with LVO, for both patients who did receive EST and those that did not.

Abstract TP379: The Impact of a Nurse Navigator-Centered Discharge Plan on Care Transitions for Patients Discharged From a Comprehensive Stroke Center

Background: An effective care transition plan at the time of a stroke discharge impacts risk factor control, readmissions, and patient satisfaction. In our Comprehensive Stroke Center (CSC), we assigned a registered nurse to be our Stroke Nurse Navigator (SNN). The SNN meets with patients and caregivers prior to discharge to address care transition needs and answers the Stroke Nurse Helpline to provide assistance after discharge.

Purpose: To assess the impact of the SNN in meeting care transition needs of patients discharged home from a CSC

Methods: Stroke patients in our CSC are called within 72 hours after home discharge, and a standard questionnaire is used to assess satisfaction with the discharge process. We compared post-discharge callback data from stroke patients during a 6-month period before (1/1/18 to 6/30/18) and after (7/1/18 to 12/31/18) designation of the SNN.

Results: Among 413 stroke patients who completed questionnaires, 207 were pre-SNN and 206 were post-SNN, representing 55% and 47% of home discharges respectively. There was a 46% decrease in all concerns: 74% in non-clinical concerns, 70% in complaints about hospital experience, and 45% in reported early admissions (Table 1). There were fewer reported concerns about activity restrictions and assistive devices (100% decrease), outpatient therapy (76% decrease), prescriptions (75% decrease), outpatient testing (60% decrease), and other discharge information (29%). There were more concerns related to clinical symptoms after hospitalization (36% increase), establishing care with primary provider or neurologist (36% increase), and understanding home medications.

Conclusion: SNNs may play a role in meeting care transition needs of stroke patients by providing assistance before and early after a home discharge. SNNs may foster heightened awareness among stroke patients and caregivers about following through on recommended post-hospital care for better recovery outcomes.

Abstract WP455: Memorial Hermann Hospital System Stroke Coordinators: Working as One

Background: Many hospital stroke programs fail to meet or maintain the certification requirements of The Joint Commission (TJC) as a Primary Stroke Center (PSC) or Comprehensive Stroke Center (CSC). The most common reason is the absence of a dedicated stroke program coordinator. There are opportunities for improvement to promote stroke coordinator growth and retention.

Purpose: We created The Memorial Hermann Hospital System Stroke Coordinator Alliance to combine resources, reduce workload, and support stroke coordinators in order to promote adherence to best practice and maintain TJC stroke certification.

Methods: The Memorial Hermann Hospital System Stroke Coordinator Alliance was developed in 2015. It includes 14 nurses who represent 11 acute care hospitals within a large hospital system in Houston (Figure1). Four of the hospitals are CSCs, five are PSCs, and two are not certified. Monthly meetings are conducted to create standardized access to resources, stroke coordinator orientation, education, medical power plans, process improvement, and data development. Coordinator work groups, a central email and shared drive, biweekly data meetings, and a buddy system were created to reduce work load, improve electronic communication, and streamline data review procedures. A partnership was created to onboard new coordinators and to prepare for mock and real time survey visits. In 2018 data abstraction was standardized across hospitals with use of a homegrown database Stroke Program Registry (REGIS).

Results: Of the 14 Stroke Coordinators in place during fiscal years 2015 - 2019, retention was 100%. A total of 19 stroke surveys were completed and recognized as successful by The Joint Commission. A total of 17,148 stroke patients were received with PSC measures averaging greater than 95% and CSC measures above 90%.

Conclusion: Implementing program development support for stroke coordinators improves retention and quality care in a high volume stroke system.

Abstract TP404: Optimizing Length of Stay Through an Integrated Communication Strategy

Background: At our comprehensive stroke center, the Stroke Unit bed ahead tool allows bed availability to be reported every four hours and identifies patients who may be available for discharge or transfer out of the unit. A Stroke Bed Ahead Algorithm is utilized and information is communicated using a paper format and an online text messaging system called EZ Texting.

Purpose: The purpose of this study is to improve bed flow through coordination and facilitation of movement in the Stroke Unit and to provide quality control feedback of the efficiency of bed flow within the Stroke Unit. A bed ahead tool is utilized to decrease divert activity of the hospital and decrease length of stay on the Stroke Unit, thereby decreasing length of stay in the hospital.

Intervention: The Stroke Unit charge and staff nurses evaluate patients appropriate for possible discharge or transfer out of the Stroke Unit. A Stroke Unit capacity text message is then sent out by the Charge Nurse or the Unit Coordinator every four hours starting at 0800. The capacity text message includes the total number of patients and patients pending to be received or transferred out of the unit.

Results: Utilizing an integrated communication strategy decreased the length of stay of stroke population by 12%.

Implications of Practice: Implementation of Stroke Unit capacity notification system decreases the length of stay and decreases divert activity of the hospital.

A Prospective Study on the Impact and Out-of-Pocket Costs of Dengue Illness in International Travelers

Although the costs of dengue illness to patients and households have been extensively studied in endemic populations, international travelers have not been the focus of costing studies. As globalization and human travel activities intensify, travelers are increasingly at risk for emerging and reemerging infectious diseases, such as dengue. This exploratory study aims to investigate the impact and out-of-pocket costs of dengue illness among travelers. We conducted a prospective study in adult travelers with laboratory-confirmed dengue and recruited patients at travel medicine clinics in eight different countries from December 2013 to December 2015. Using a structured questionnaire, we collected information on patients and their health-care utilization and out-of-pocket expenditures, as well as income and other financial losses they incurred because of dengue illness. A total of 90 patients participated in the study, most of whom traveled for tourism (74%) and visited countries in Asia (82%). Although 22% reported hospitalization and 32% receiving ambulatory care while traveling, these percentages were higher at 39% and 71%, respectively, after returning home. The out-of-pocket direct and indirect costs of dengue illness were US$421 (SD 744) and US$571 (SD 1,913) per episode, respectively, averaging to a total out-of-pocket cost of US$992 (SD 2,052) per episode. The study findings suggest that international travelers incur important direct and indirect costs because of dengue-related illness. This study is the first to date to investigate the impact and out-of-pocket costs of travel-related dengue illness from the patient's perspective and paves the way for future economic burden studies in this population.

Determination of Lead in Wine by Graphite Furnace Atomic Absorption Spectrophotometry: Interlaboratory Study

An interlaboratory study of a graphite furnace atomic absorption spectrophotometry (GFAAS) method for the determination of lead in wine was conducted. Seventeen laboratories from France, United States, and the United Kingdom, using a variety of GFAAS instruments, took part in the study. The method incorporated a novel matrix-matching procedure to minimize matrix effects between standards and samples. Six wine test materials were prepared and sent to participants as 12 blind duplicate or split level samples. There was good agreement between results obtained from participants and target values (24–279 μg/L) obtained with an inductively coupled plasma-mass spectrometry method. The precision of the GFAAS method was well within the range predicted by the Horwitz equation for the 6 test materials analyzed. Repeatability standard deviations ranged from 3 to 17%. Reproducibility standard deviations were in the range of 10 to 30%. The method is recommended for use for official purposes.

Exploring the Structure of the Bound Proton with Deeply Virtual Compton Scattering

In the past two decades, deeply virtual Compton scattering of electrons has been successfully used to advance our knowledge of the partonic structure of the free proton and investigate correlations between the transverse position and the longitudinal momentum of quarks inside the nucleon. Meanwhile, the structure of bound nucleons in nuclei has been studied in inclusive deep-inelastic lepton scattering experiments off nuclear targets, showing a significant difference in longitudinal momentum distribution of quarks inside the bound nucleon, known as the EMC effect. In this Letter, we report the first beam spin asymmetry (BSA) measurement of exclusive deeply virtual Compton scattering off a proton bound in ^{4}He. The data used here were accumulated using a 6 GeV longitudinally polarized electron beam incident on a pressurized ^{4}He gaseous target placed within the CLAS spectrometer in Hall-B at the Thomas Jefferson National Accelerator Facility. The azimuthal angle (ϕ) dependence of the BSA was studied in a wide range of virtual photon and scattered proton kinematics. The Q^{2}, x_{B}, and t dependencies of the BSA on the bound proton are compared with those on the free proton. In the whole kinematical region of our measurements, the BSA on the bound proton is smaller by 20% to 40%, indicating possible medium modification of its partonic structure.

Phase stabilization by electronic entropy in plutonium

Plutonium metal undergoes an anomalously large 25% collapse in volume from its largest volume δ phase (δ-Pu) to its low temperature α phase, yet the underlying thermodynamic mechanism has largely remained a mystery. Here we use magnetostriction measurements to isolate a previously hidden yet substantial electronic contribution to the entropy of δ-Pu, which we show to be crucial for the stabilization of this phase. The entropy originates from two competing instabilities of the 5f-electron shell, which we show to drive the volume of Pu in opposing directions, depending on the temperature and volume. Using calorimetry measurements, we establish a robust thermodynamic connection between the two excitation energies, the atomic volume, and the previously reported excess entropy of δ-Pu at elevated temperatures.

Plutonium has strong electronic correlations, which makes it difficult to establish microscopic understanding of the complicated structural phase diagram. Here the authors identify an electronic contribution to the entropy that stabilises the δ-Pu phase.

Direct Observation of Proton-Neutron Short-Range Correlation Dominance in Heavy Nuclei

We measured the triple coincidence A(e,e^{'}np) and A(e,e^{'}pp) reactions on carbon, aluminum, iron, and lead targets at Q^{2}>1.5  (GeV/c)^{2}, x_{B}>1.1 and missing momentum >400  MeV/c. This was the first direct measurement of both proton-proton (pp) and neutron-proton (np) short-range correlated (SRC) pair knockout from heavy asymmetric nuclei. For all measured nuclei, the average proton-proton (pp) to neutron-proton (np) reduced cross-section ratio is about 6%, in agreement with previous indirect measurements. Correcting for single-charge exchange effects decreased the SRC pairs ratio to ∼3%, which is lower than previous results. Comparisons to theoretical generalized contact formalism (GCF) cross-section calculations show good agreement using both phenomenological and chiral nucleon-nucleon potentials, favoring a lower pp to np pair ratio. The ability of the GCF calculation to describe the experimental data using either phenomenological or chiral potentials suggests possible reduction of scale and scheme dependence in cross-section ratios. Our results also support the high-resolution description of high-momentum states being predominantly due to nucleons in SRC pairs.

First Measurements of the Double-Polarization Observables F, P, and H in ω Photoproduction off Transversely Polarized Protons in the N^{*} Resonance Region

First measurements of double-polarization observables in ω photoproduction off the proton are presented using transverse target polarization and data from the CEBAF Large Acceptance Spectrometer (CLAS) FROST experiment at Jefferson Lab. The beam-target asymmetry F has been measured using circularly polarized, tagged photons in the energy range 1200-2700 MeV, and the beam-target asymmetries H and P have been measured using linearly polarized, tagged photons in the energy range 1200-2000 MeV. These measurements significantly increase the database on polarization observables. The results are included in two partial-wave analyses and reveal significant contributions from several nucleon (N^{*}) resonances. In particular, contributions from new N^{*} resonances listed in the Review of Particle Properties are observed, which aid in reaching the goal of mapping out the nucleon resonance spectrum.

Abstract WP489: Evaluation of Post-discharge Callback Data from Stroke Patients and Caregivers

Background and Purpose: The early period after hospital discharge is a critical time for stroke patients during which transitions of care can be optimized. In our Comprehensive Stroke Center, patients are called within 3 days of discharge to conduct point of service feedback utilizing yes/no and open-ended questions related to the hospital stay, discharge instructions, follow-up care, and prescriptions. We sought to examine post-discharge feedback to identify areas of need.

Methods: A multidisciplinary team collaborated to classify callback responses for patients discharged from 1/1/2018 to 6/30/2018 within the following domains from the Hospital Consumer Assessment of Healthcare Providers and Systems survey: care from doctors, care from nurses, hospital environment, experience in the hospital, and transitions of care. We provide a descriptive analysis (Table 1).

Results: Among 700 patients discharged in the study period, 378 (54%) were discharged home and 207 (55%) of these were contacted for feedback. Eighty four (40.5%) of patients/caregivers expressed at least one concern (129 total), with the largest proportion in the transitions of care domain (67.4 %). Patients reported difficulties with prescriptions (15.5%), obtaining outpatient therapy services (13.2%) and follow-up appointments (10.9%), new or persistent clinical symptoms (8.5%), and insufficient hospital discharge education (5.4%). Approximately 5% (11/207) of all patients reported hospital readmission during the call.

Conclusions: This study reveals that stroke patients and caregivers identify transitional care as an area for improvement following discharge from a CSC. Interventions aimed at facilitating care from hospital to home after stroke are warranted, and we are implementing patient-centered initiatives to enhance the discharge process and provide additional support early after stroke discharge.

Heart Under Attack: Cardiac Manifestations of Inflammatory Bowel Disease

There is a well-established association between chronic inflammation and an elevated risk of heart disease among patients with systemic autoimmune conditions. This review aims to summarize existing literature on the relationship between inflammatory bowel disease and ischemic heart disease, heart failure, arrhythmia, and pericarditis, with particular attention to approaches to management and treatment.

Center of Mass Motion of Short-Range Correlated Nucleon Pairs studied via the A(e,e^{'}pp) Reaction

Short-range correlated (SRC) nucleon pairs are a vital part of the nucleus, accounting for almost all nucleons with momentum greater than the Fermi momentum (k_{F}). A fundamental characteristic of SRC pairs is having large relative momenta as compared to k_{F}, and smaller center of mass (c.m.) which indicates a small separation distance between the nucleons in the pair. Determining the c.m. momentum distribution of SRC pairs is essential for understanding their formation process. We report here on the extraction of the c.m. motion of proton-proton (pp) SRC pairs in carbon and, for the first time in heavier and ansymetric nuclei: aluminum, iron, and lead, from measurements of the A(e,e^{'}pp) reaction. We find that the pair c.m. motion for these nuclei can be described by a three-dimensional Gaussian with a narrow width ranging from 140 to 170  MeV/c, approximately consistent with the sum of two mean-field nucleon momenta. Comparison with calculations appears to show that the SRC pairs are formed from mean-field nucleons in specific quantum states.

Highly Asymmetric Nodal Semimetal in Bulk SmB_{6}

We show that novel low temperature properties of bulk SmB_{6}, including the sudden growth of the de Haas-van Alphen (dHvA) amplitude (and heat capacity) at millikelvin temperatures and a previously unreported linear-in-temperature bulk electrical conductivity at liquid helium temperatures, signal the presence of a highly asymmetric nodal semimetal. We show that a highly asymmetric nodal semimetal is also a predicted property of the Kondo lattice model (with dispersionless f-electron levels) in the presence of Sm vacancies or other defects. We show it can result from a topological transformation of the type recently considered by Shen and Fu and eliminates the necessity of a neutral Fermi surface for explaining bulk dHvA oscillations in SmB_{6}.

Predictors for influenza vaccine acceptance among patients with inflammatory rheumatic diseases

BACKGROUND

Patients with inflammatory rheumatic diseases are at higher risk for influenza and current guidelines recommend vaccination for this group of patients. The aim of this study was to evaluate the vaccination coverage and predictors for influenza vaccination among patients with inflammatory rheumatic diseases.

METHODS

This survey was conducted at the outpatient rheumatology clinic at the Medical University of Vienna between July and October 2017. All patients diagnosed with an inflammatory rheumatic disease and receiving immunosuppressive therapy were asked to complete a questionnaire about their influenza vaccination status for 2016/17.

RESULTS

490 patients with rheumatic diseases completed a questionnaire (33% male, mean age 55.3 years). The influenza vaccination rate for the previous season was 25.3% (n = 124/490). Predictors for a positive influenza vaccination status were higher age (Adjusted Odds Ratio 5.0, 95% Confidence Interval 2.4-10.4) and treatment with biological disease-modifying antirheumatic drugs (AOR 2.0, 95% CI 1.3-3.1). Patients who received a recommendation for influenza vaccination by their general practitioner were significantly more likely to be vaccinated than those who did not (57% vs. 15%, AOR 6.6, 95% CI 4.1-10.8); even more so if they received a recommendation by their rheumatologist (62% vs. 19%, AOR 9.0, 95% CI 4.9-16.5). The main reasons for patients to decline influenza vaccination were fear of side effects (36%), concerns that vaccination might not be effective due to their immunosuppressed condition (38%) or that it might worsen the rheumatic disease (20%).

CONCLUSIONS

A moderate influenza vaccination rate of 25.3% was detected among patients with inflammatory rheumatic diseases. Recommendation of the influenza vaccine by a physician exerts the most effective impact on a positive vaccination status.

Alimentary microbes of winter-form Drosophila suzukii

Drosophila suzukii (Matsumura) (Diptera: Drosophilidae) is a damaging pest of fruit. Reproductively diapausing adults overwinter in woodlands and remain active on warmer winter days. It is unknown if this adult phase of the lifecycle feeds during the winter period, and what the food source may be. This study characterized the flora in the digestive tract of D. suzukii using a metagenomics approach. Live D. suzukii were trapped in four woodlands in the south of England and their guts dissected for DNA extraction and amplicon-based metagenomics sequencing (internal transcribed spacer and 16S rRNA). Analysis at genus and family taxonomic levels showed high levels of diversity with no differences in digestive tract bacterial or fungal biota between woodland sites of winter-form D. suzukii. Female D. suzukii at one site appeared to have higher bacterial diversity in the alimentary canal than males, but there was a site, sex interaction. Many of the biota were associated with cold, wet climatic conditions and decomposition. This study provides the first evidence that winter-form D. suzukii may be opportunistic feeders during the winter period and are probably exploiting food sources associated with moisture on decomposing vegetation during this time. A core gut microbiome has been identified for winter-form D. suzukii.

Effect of peritoneal dialysis fluids on activity of echinocandins against Candida spp. biofilm

Peritoneal dialysis fluids (PDFs) impair microorganisms' growth, which may compromise effectivity of some antimicrobials. The purpose of this study was to investigate the effect of three different PDFs (lactate/bicarbonate-buffered Physioneal 40® with 2.2% glucose, lactate-buffered Nutrineal PD4® with 1.1% amino acid, and lactate-buffered Extraneal® with 7.5% icodextrin) on biofilm formation of four different Candida spp and antibiofilm effectiveness of anidulafungin, caspofungin and micafungin against Candida spp. biofilm in PDFs. All tested PDFs attained inhibitory effect on the biofilm formation but also reduced biofilm effectiveness of echinocandins against biofilm in PDFs was detected.

Measurement of the Q^{2} Dependence of the Deuteron Spin Structure Function g_{1} and its Moments at Low Q^{2} with CLAS

We measured the g_{1} spin structure function of the deuteron at low Q^{2}, where QCD can be approximated with chiral perturbation theory (χPT). The data cover the resonance region, up to an invariant mass of W≈1.9  GeV. The generalized Gerasimov-Drell-Hearn sum, the moment Γ_{1}^{d} and the spin polarizability γ_{0}^{d} are precisely determined down to a minimum Q^{2} of 0.02  GeV^{2} for the first time, about 2.5 times lower than that of previous data. We compare them to several χPT calculations and models. These results are the first in a program of benchmark measurements of polarization observables in the χPT domain.

Abstract NS5: It Takes a Village: And Other Lessons Learned from a Large Volume Comprehensive Stroke Center

Introduction: The Joint Commission (TJC) certification as a Comprehensive Stroke Center (CSC) entails coordination across multiple units of clinical / academic institutions, and the demands on resources are daunting. Certification standards lack resource allocation recommendations. We present data on workload quantum and resource requirements based on experiences from a TJC certified, high-volume CSC.

Methods: We conducted a desk audit of frequency-based CSC staff activities. An outside team member conducted interviews, followed by collective adjudication for precise categorization. Redundant and overlapping tasks were removed iteratively, and activities were cross-linked with other sources (meeting minutes, individual calendars, on-call schedules). Person-time per task is a product of number of hours and team members. Person-Hours/Day (PHD) were determined by factoring task frequency. PHDs were used to calculate Full Time Employee (FTE) requirements. Volumes were obtained from our CSC registries.

Results: Our CSC received 2,840 patients between 4/1/2016 and 3/31/2017. Among ischemic stroke patients, 30.5% received IV tPA and 119 underwent intra-arterial thrombectomy. Overall, 60 independent activities were divided into 7 mutually exclusive categories (Table 1). Daily, weekly, and monthly activities collectively constituted 83.3% of all the activities. A total of 67.43 PHDs were computed of which data processes are the most resource consumptive (32.07 PHD) followed by core measures tracking (13.8 PHD) (Figure 1). Collectively, the top two activities account for 68% of all PHD and approximate a requirement of six FTEs. Details of activities will be presented.

Conclusion: Adequate planning and continual assessment of resources is imperative to optimal CSC operations and patients’ quality of care. Resources are significantly volume driven. Integrative nature of data processes are central to CSC functioning and necessitate resource evaluation.

First Exclusive Measurement of Deeply Virtual Compton Scattering off ^{4}He: Toward the 3D Tomography of Nuclei

We report on the first measurement of the beam-spin asymmetry in the exclusive process of coherent deeply virtual Compton scattering off a nucleus. The experiment uses the 6 GeV electron beam from the Continuous Electron Beam Accelerator Facility (CEBAF) accelerator at Jefferson Lab incident on a pressurized ^{4}He gaseous target placed in front of the CEBAF Large Acceptance Spectrometer (CLAS). The scattered electron is detected by CLAS and the photon by a dedicated electromagnetic calorimeter at forward angles. To ensure the exclusivity of the process, a specially designed radial time projection chamber is used to detect the recoiling ^{4}He nuclei. We measure beam-spin asymmetries larger than those observed on the free proton in the same kinematic domain. From these, we are able to extract, in a model-independent way, the real and imaginary parts of the only ^{4}He Compton form factor, H_{A}. This first measurement of coherent deeply virtual Compton scattering on the ^{4}He nucleus, with a fully exclusive final state via nuclear recoil tagging, leads the way toward 3D imaging of the partonic structure of nuclei.

Contemporary Epidemiology of Catheter-Associated Urinary Tract Infections (CAUTIs) in a Tertiary Care Center: Is Foley Re-Insertion a Novel Risk Factor?

Background

CAUTIs are one of the most common causes of hospital-acquired infections. We report on a retrospective analysis performed on prospectively collected CAUTI surveillance data from 2014 to 2016 at a large tertiary care academic hospital

Methods

A total of 181 CAUTIs by NHSN definition were reviewed to describe contemporary demographics, risk factors, microbiology, and outcomes.

Results

The 181 CAUTIs involved 178 patients. 61% were female. Events mostly occurred in an ICU setting (65%), specifically our neurosurgical unit (23%), followed by floors (24%) and intermediate units (11%). Most episodes occurred within a week after the initial catheter insertion (60%). 40% of CAUTIs occurred within an average of 5.5 days (SD ± 5.12) after a Foley re-insertion. Of the 221 cultured micro-organisms, Gram-negatives accounted for 74% (predominately K. pneumoniae and E. coli), followed by Gram-positives and yeast at 18% and 8%, respectively. 8% of organisms showed multi-drug resistance, 8% of patients developed C. difficile co-infections, 23% had concomitant bacteremia, and the length of stay averaged 28 days (SD ± 26.74). 55% of patients were discharged to another facility. 12% of patients expired and 4% were discharged to hospice

Conclusion

We describe the contemporary demographics, microbiology and outcomes of CAUTIs in a large tertiary care center. We also found that 40% of our CAUTIS are associated with a Foley removal and re-insertion event. Reasons requiring catheter exchanges and reinsertions include leakage, bleeding, obstruction, failed voiding trial, and general malfunction. Although this observation needs to be confirmed case control studies and larger observational trials, this new insight may provide an opportunity to intervene and focus infection prevention interventions in this novel high-risk population.

Disclosures

All authors: No reported disclosures.

Dalbavancin for outpatient parenteral antimicrobial therapy of skin and soft tissue infections in a returning traveller : Proposal for novel treatment indications

Skin and soft tissue infections (SSTIs) are among the most common health problems in travellers returning from tropical and subtropical countries. Importantly, the prevalence of Staphylococcus aureus, the most common pathogen for purulent SSTIs, with specific drug resistance, such as methicillin resistant Staphylococcus aureus (MRSA) and those expressing virulence genes, such as Panton-Valentine-leukocidin is higher in tropical regions than in most high resource settings. This poses challenges for the empirical antimicrobial treatment of SSTIs in returning travellers. This short report describes a patient with a recent travel history to Hong Kong, Singapore and the Philippines who presented with multiple mosquito bites on both upper extremities and secondary bacterial superinfection. He had previously been prescribed oral beta-lactam antimicrobial therapy but lacked adherence to this treatment. Based on the risk for MRSA infection and problems with treatment adherence to oral therapy an outpatient parenteral antimicrobial therapy with dalbavancin was administered on days 0 and 7. Microbiological culture confirmed presence of MRSA and clinical follow-up demonstrated complete remission of the SSTI within 2 weeks. Dalbavancin is a promising treatment option for empirical parenteral treatment of SSTIs in returning travellers, a population at high risk for beta-lactam resistant S. aureus skin infections.

Beam-Target Helicity Asymmetry for γ[over →]n[over →]→π^{-}p in the N^{*} Resonance Region

We report the first beam-target double-polarization asymmetries in the γ+n(p)→π^{-}+p(p) reaction spanning the nucleon resonance region from invariant mass W=1500 to 2300 MeV. Circularly polarized photons and longitudinally polarized deuterons in solid hydrogen deuteride (HD) have been used with the CEBAF Large Acceptance Spectrometer (CLAS) at Jefferson Lab. The exclusive final state has been extracted using three very different analyses that show excellent agreement, and these have been used to deduce the E polarization observable for an effective neutron target. These results have been incorporated into new partial wave analyses and have led to significant revisions for several γnN^{*} resonance photocouplings.

Magnetic field tuning of an excitonic insulator between the weak and strong coupling regimes in quantum limit graphite

The excitonic insulator phase has long been predicted to form in proximity to a band gap opening in the underlying band structure. The character of the pairing is conjectured to crossover from weak (BCS-like) to strong coupling (BEC-like) as the underlying band structure is tuned from the metallic to the insulating side of the gap opening. Here we report the high-magnetic field phase diagram of graphite to exhibit just such a crossover. By way of comprehensive angle-resolved magnetoresistance measurements, we demonstrate that the underlying band gap opening occurs inside the magnetic field-induced phase, paving the way for a systematic study of the BCS-BEC-like crossover by means of conventional condensed matter probes.

Progressive Perforation of the Nasal Septum Due to Leishmania major: A Case of Mucosal Leishmaniasis in a Traveler

This report describes a case of mucosal leishmaniasis caused by Leishmania major with destructive perforation of the nasal septum illustrating the diagnostic challenges of a rare clinical presentation of L. major infection in a traveler. The atypical presentation may have been associated with the use of cortisone as a potential trigger for the progressive destruction of the nasal septum.

Joint Hypermobility Syndrome and Anxiety Disorder: Structural Brain Correlates

Introduction

Joint hypermobility syndrome/Ehlers Danlos III (JHS/EDS III) is a common, connective tissue condition. This group is over-represented in panic/anxiety disorders and exhibits autonomic abnormalities and heightened interoceptive sensibility. Previous neuroimaging in healthy volunteers with hypermobility has observed differences in key emotional brain regions, notably amygdala and insula.

Aims and objective To explore, in a clinical population, the structural brain correlates underpinning the association between JHS/EDS III and anxiety.

Method

Seventy participants were divided into four experimental groups: (2 × 2 factor design: presence/absence of hypermobility; presence/absence of anxiety). Hypermobility was assessed using Brighton Criteria. All participants underwent brief tests of autonomic function and interoception. Structural images were obtained using a 1.5 T MRI scanner. Results are reported at whole brain uncorrected significance threshold of P < 0.001.

Results

Comparison of grey matter volume revealed increased insular volume in anxious patients with JHS/EDS-III compared to anxious patients without (Fig. 1A, B), correlating with initial peak heart rate on standing. Additionally, amygdala volume correlated with hypermobility score in anxious patients, but not in non-anxious individuals (Fig. 1C, D). Amygdala volume correlated with interoceptive accuracy.

Conclusions

This data implicates amygdala and insula as likely neural substrates mediating clinical relationships between hypermobility syndrome and anxiety, demonstrating the relevance of autonomic and interoceptive influences on this relationship. Further work hopes to explore functional and structural connectivity between these regions in JHS/EDS-III.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Quality Programs in Neurosurgery: The Memorial Hermann/University of Texas Experience

The importance of outcome measures is steadily increasing due to the rise of "pay for performance" and the advent of population health. In 2007, a quality initiative was started due to poor performance on rankings such as the University Health Consortium (UHC) report card. Inherent to all such efforts are common challenges: how to engage the providers; how to gather and ensure the accuracy of the data; how to attribute results to individuals; how to ensure permanent improvements. After analysis, a strategy was developed that included an initial focus on 3 metrics (mortality, infection rates, and complications), leadership from practicing neurosurgeons, protocol development and adherence, and subspecialization. In addition, it was decided that the metrics would initially apply to attending physicians only, but that the entire team would need to be involved. Once the fundamental elements were established, the process could be extended to other measures and providers. To support this effort, special information system tools were developed and a support team formed. As the program matured, measured outcomes improved and more metrics were added (to a current total of 48). For example, UHC mortality ratios (observed over expected) decreased by 75%. Infection rates decreased 80%. The program now involves all trainee physicians, advanced practice providers, nurses, and other staff. This paper describes the design, implementation, and results of this effort, and provides a practical guide that may be useful to other groups undertaking similar initiatives.

Variability of respiratory rate measurements in children suspected with non-severe pneumonia in north-east Tanzania

OBJECTIVE

Measurement of respiratory rate is an important clinical sign in the diagnosis of pneumonia but suffers from interobserver variation. Here, we assess the use of video recordings as a quality assurance tool that could be useful both in research and in training of staff.

METHODS

Respiratory rates (RR) were recorded in children aged 2-59 months presenting with cough or difficulty breathing at two busy outpatient clinics in Tanzania. Measurements were repeated at 10-min intervals in a quiet environment with simultaneous video recordings that were independently reviewed by two paediatricians.

RESULTS

Eight hundred and fifty-nine videos were sent to two paediatricians; 148 (17.2%) were considered unreadable by one or both. For the 711 (82.8%) videos that were readable by both paediatricians, there was perfect agreement for the presence of raised RR with a kappa value (κ) of 0.85 (P < 0.001); and in 476 (66.9%) cases, both paediatricians agreed on the RR within 2 breaths per minute (±2 bpm). A reported illness of 5 days or more was associated with unreadable video recordings (OR = 3.44, CI: 1.5-6.08; P < 0.001). The multilevel model showed that differences between observers accounted for only 13% of the variability in RR.

CONCLUSION

Video recordings are reliable tools for quality assurance of RR measurements in children with suspected pneumonia. Videos with a clear view of respiratory movements may also be useful in training primary healthcare staff.

Abstract WP341: Outcomes After Percutaneous Endoscopic Gastrostomy in Stroke Patients With Dysphagia

Learning objectives: Inability to swallow without aspiration is a common complication of acute stroke. In patients with prolonged swallowing dysfunction, a percutaneous endoscopic gastrostomy (PEG) tube is placed. Although PEG placement is an increasingly common practice, there is a paucity of and sometimes conflicting information about utility and clinical outcomes after PEGs. PEG complications can range from minor to major and complication rates range from 16-75%. For a better understanding of PEG complications versus recovery of swallowing a retrospective study was performed on acute stroke patients who had a failed swallow evaluation and had a PEG placed.

Methods: A retrospective review was performed of all patients with acute ischemic and hemorrhagic stroke admitted to a large academic medical center who had a PEG placed after failing a swallowing study between January 2016 and March 2016. Complications reviewed included acute bleeding within 24 hours, chronic GI bleeding related to PEG, inadvertent dislodging of PEG, PEG infections and unexpected return to the operating room. Additionally, information about recovery of swallowing function was collected.

Results: 64 patients were included. Average age was 70 years (SD 13.5). A PEG was placed on average 9.1 (SD 5.3) days into hospitalization and LOS averaged 7.6 days (SD 7.7) after PEG placement. The total number of patients who experienced a complication after PEG placement was 14 (21.9%). The most common complications were PEG infections, 6 patients (9.4%) and GI bleeding within 30 days of PEG placement, 6 patients (9.4%). There were 2 inadvertently pulled PEGs (3.1%) and 2 unexpected returns to the OR (3.1%). Out of the complications 2 (3.1%) resulted in death, 2 (3.1%) required surgical intervention. At least 20 patients recovered swallowing within a median of 26 days. At least 5 (7.8%) patients achieved recovery of swallow function within 14 days of PEG placement. Five patients had PEGs placed for inability to swallow liquids.

Conclusions: In the acute stroke population, placement of PEG tubes was associated with a 21.9% complication rate and a 3.1% risk of mortality.

Predictors for and coverage of influenza vaccination among HIV-positive patients: a cross-sectional survey

OBJECTIVES

Influenza vaccination is recommended for HIV-infected patients, but limited data about vaccination rates are available. The aim of this study was to evaluate the coverage of and predictors for influenza vaccination among HIV-positive patients.

METHODS

All HIV-positive patients who visited the HIV out-patient department of the University Hospital of Vienna, Austria, between June and August 2015 were asked to participate in this survey by completing a questionnaire.

RESULTS

A total of 455 HIV-positive patients completed a questionnaire, with 359 male and 96 female participants with a mean age of 46 years. The influenza vaccination rate for the previous season (2014/2015) was 11.9% [n = 54/455; 95% confidence interval (CI) 9.2-15.2%]. Older age was significantly associated with a positive influenza vaccination status. Obtaining information through a medical consultation or receiving a direct recommendation for vaccination by a physician had a significant impact on vaccination behaviour. The probability of being vaccinated against influenza was about 13 times higher among patients who received a recommendation for vaccination by their family physician or by their HIV specialist (P < 0.001). Important reasons for declining vaccination were fear of side effects (39%), not considering influenza as a severe disease (36%) and reasons related to HIV: 17% were worried that the vaccine could worsen the course of HIV infection and 16% believed vaccination would fail because of their compromised immune system.

CONCLUSIONS

A low influenza vaccination rate of 11.9% was detected in this HIV-positive cohort. The most effective impact for a positive vaccination status was direct recommendation of the influenza vaccine by the attending physician.