The Association of Mental Health and Substance Use With Retention in HIV Care Among Black Women in Washington, District of Columbia

BACKGROUND

Black women with HIV are impacted by mental health and substance use disorders alongside barriers to care. The impact of these disorders on retention in care, a crucial step of the HIV care continuum, has not been well-studied. We examined the association between these disorders and retention in care over a 2-year period.

METHODS

Data from January 1, 2011, to June 30, 2019, were obtained from the DC Cohort, an observational HIV study in Washington, District of Columbia. We examined the associations between mental health (i.e., mood-related or trauma-related) or substance use disorders, separately, on not being retained in HIV care over a 2-year interval post-enrollment among non-Hispanic Black women with HIV. Multivariate logistic regression with adjusted odds ratios (aORs) for sociodemographic and clinical variables was used to quantify the association of 1) having a confirmed mental health or substance use disorder and 2) not being retained in care.

RESULTS

Among the 2,181 women in this analysis, 690 (31.64%) were not retained in care. The prevalence of a mood-related disorder (39.84%) was higher compared with a substance use (16.19%) or trauma-related disorder (7.75%). Age per a 10-year increase (aOR 0.87; confidence interval [CI] 0.80, 0.94) and a mood-related disorder diagnosis (aOR 0.72; CI: 0.59, 0.88) were inversely associated with not being retained in care.

CONCLUSION

Mood-related disorders were prevalent among Black women with HIV in Washington, District of Columbia, but were not associated with worse retention in care. Future studies should examine key facilitators for Black women with HIV and coexisting mood-related disorders and how they impact retention in care.

Tinkering with care: Implementing extended-release buprenorphine depot treatment for opioid dependence

We examine how extended-release buprenorphine depot (BUP-XR) is put to use and made to work in implementation practices, attending to how care practices are challenged and adapted as a long-acting technology is introduced into service in opioid agonist treatment (OAT) in Australia. Our approach is informed by ideas in science and technology studies (STS) emphasising the irreducible entanglement of care practices and technology, and in particular the concept of 'tinkering' as a practice of adaptation. To make our analysis, we draw on qualitative interview accounts (n = 19) of service providers involved in BUP-XR implementation across five sites. Our analysis considers the disruptive novelty of BUP-XR. Tinkering to make a novel technology work in practice slows down the expectation of implementation in relation to transformative innovation, despite the promise of dramatic or rapid change. Tinkering allowed for more open relations, for new care practices that departed from the routine and familiar, opening potential for how BUP-XR could be put to use and made to work in its new situation, and as its situation evolved along-with its implementation. Flexibility and openness of altering relations was, however, at times, held in tension with inflexibility and closure. This analysis identifies a concern for what is made present and what is made absent in the altered care network affected by BUP-XR, with the multiple effects of supervised daily dosing practices thrown into relief as they become absented. Tinkering to implement BUP-XR locally connects with a broader assemblage of trial and movement in the constitution of treatment. The introduction of long-acting technologies prompts new questions about embedded implementation practices, including supervised dosing, urinalysis, the time and place of psychosocial support, and how other social aspects of care might be recalibrated in drug treatment.

Deliberative Improvement of Oral Care Quality: The Horizon Europe DELIVER Project

KNOWLEDGE TRANSFER STATEMENT

The EU DELIVER project aims to enhance the quality of oral health care through codevelopment and coproduction of solutions together with citizens/patients, providers, and policymakers. The unique multicountry nature of the project will facilitate fast-track prototype development and testing of innovative QI approaches in select countries. Reflective learning regarding the transferability of findings between different countries and settings offers unique opportunities to drive progress toward context-specific implementation of innovative oral health care QI approaches. The collective knowledge gained from the 7 European countries involved in DELIVER can also generate knowhow for improving the quality of oral health care in other countries around the globe.

Evaluation of New Hypertension Guidelines on the Prevalence and Control of Hypertension in a Clinical HIV Cohort: A Community-Based Study

The prevalence and control of hypertension (HTN) among people with HIV (PWH) have not been widely studied since the release of newer 2017 ACC/AHA guidelines ("new guidelines"). To address this research gap, we evaluated and compared the prevalence and control of HTN using both 2003 JNC 7 ("old guidelines") and new guidelines. We identified 3,206 PWH with HTN from the DC Cohort study in Washington, DC, between January 2018 and June 2019. We defined HTN using International Classification of Diseases (ICD)-9/-10 diagnosis codes for HTN or ≥2 blood pressure (BP) measurements obtained at least 1 month apart (>139/89 mm Hg per old or >129/79 mm Hg per new guidelines). We defined HTN control based on recent BP (≤129/≤79 mm Hg per new guidelines). We identified socio-demographics, cardiovascular risk factors, and co-morbidities associated with HTN control using multivariable logistic regression [adjusted odds ratio (aOR); 95% confidence interval (CI)]. The prevalence of HTN was 50.9% per old versus 62.2% per new guidelines. Of the 3,206 PWH with HTN, 887 (27.7%) had a recent BP ≤129/≤79 mm Hg, 1,196 (37.3%) had a BP 130-139/80-89 mm Hg, and 1,123 (35.0%) had a BP ≥140/≥90 mm Hg. After adjusting for socio-demographics, cardiovascular risk factors, and co-morbidities, factors associated with HTN control included age 60-69 (vs. <40) years (aOR: 1.42; 95% CI: 1.03-1.98), Hispanic (vs. non-Hispanic Black) race/ethnicity (aOR 1.49; 95% CI: 1.04-2.15), receipt of HIV care at a hospital-based (vs. community-based) clinic (aOR 1.21; 95% CI: 1.00-1.47), being unemployed (aOR 1.42; 95% CI: 1.11-1.83), and diabetes (aOR 1.35; 95% CI: 1.13-1.63). In a large urban cohort of PWH, nearly two-thirds had HTN and less than one-third of those met new guideline criteria. Our data suggest that more aggressive HTN control is warranted among PWH, with additional attention to younger patients and non-Hispanic Black patients.

A Latent Class Analysis of Substance Use and Longitudinal HIV RNA Patterns Among PWH in DC Cohort

People with HIV (PWH) with substance use disorders (SUD) have worse health outcomes than PWH without SUD. Our objective was to characterize substance use patterns and their impact on longitudinal HIV RNA trajectories among those enrolled in an observational study of PWH in care in Washington, DC. Substance use by type (alcohol, cannabis, opioid, stimulant, hallucinogen, inhalant, sedative) was used to identify shared patterns of substance use using Latent Class Analysis (LCA). A multinomial logistic regression model evaluated the association between the resulting substance use classes and the membership probability in longitudinal HIV RNA trajectory groups. There were 30.1% of participants with at least one substance reported. LCA resulted in a three-class model: (1) Low-Level Substance Use, (2) Opioid Use, and (3) Polysubstance. The Opioid and Polysubstance Use classes were more likely to have a mental health diagnosis (45.4% and 53.5%; p < 0.0001). Members in the Opioid Use class were older (median age of 54.9 years (IQR 50.3-59.2) than both the Polysubstance and Low-Level Substance Use Classes (p < 0.0001). There were 3 HIV RNA trajectory groups: (1) Undetectable, (2) Suppressed, and (3) Unsuppressed HIV RNA over 18 months of follow-up. The probability of being in the unsuppressed HIV RNA group trajectory when a member of the Opioid Use or Polysubstance Use classes was 2.5 times and 1.5 times greater than the Low-Level Substance Use class, respectively. The Opioid Use and Polysubstance Use classes, with higher-risk drug use, should be approached with more targeted HIV-related care to improve outcomes.

Characterizing Indicators of Engagement in HIV-Associated Healthcare and Clinical Outcomes among People with HIV and Mpox in Washington, DC: A Nested Case-Control Study of the DC Cohort

The high proportion of people with HIV (PWH) in the 2022-2023 mpox outbreak has raised questions surrounding the association between HIV and mpox. The objectives of this study were to evaluate the association between engagement in HIV-associated healthcare and mpox diagnosis, as well as to characterize cases of mpox among PWH. The DC Cohort is a longitudinal cohort of PWH in Washington, DC. We conducted a 5:1 (controls:cases) nested case-cohort study on male participants, matching age and care site. Cases were participants with an identified mpox diagnosis. Conditional logistic regression was used to assess the impact of indicators of engagement in HIV-associated healthcare on mpox diagnosis. We identified 70 cases of mpox in DC Cohort participants randomly matched to 323 controls, for a total of 393 participants included in the analysis. Study participants were primarily non-Hispanic Black (72.3%) with a median age of 41 (IQR: 36, 50). There was no association between engagement in care and mpox diagnosis; however, low CD4 was associated with increased odds of mpox diagnosis (aOR: 4.60 (95% CI: 1.23, 17.11)). Among a cohort of PWH, engagement in care was not associated with mpox diagnosis, suggesting that the overrepresentation of PWH among mpox cases is not due to surveillance bias.

Examining the Association Between a Modified Quan-Charlson Comorbidity Index and HIV Viral Suppression: A Cross-Sectional Analysis of DC Cohort Participants

With the advancement of effective antiretroviral therapy, people with HIV live longer, and many are developing non-AIDS comorbidities. It is important to assess how comorbidities are associated with HIV-related health outcomes, such as viral suppression (VS). The aim of this study was to analyze the association between comorbidity burden, measured using a modified Quan-Charlson Comorbidity Index (QCCI), and VS (viral load result of <200 copies/mL). We hypothesized that an increase in QCCI score, indicating a higher risk for mortality, would correlate with lower likelihood of VS because of the burden of comorbidity treatment, possibly leading to worse antiretroviral adherence. Our analysis included participants from the DC Cohort Longitudinal HIV Study in Washington, DC. Eligible participants were aged ≥18 years and enrolled in the cohort as of January 1, 2018 (n = 2,471). A modified QCCI score, which weighs selected comorbidities (not including HIV/AIDS) and predicts mortality, was calculated using International Classification of Disease-9/10 codes from electronic health records. Multivariable logistic regressions were used to characterize the association between QCCI composite scores and VS. Participants were predominantly virally suppressed (89.6%), male (73.9%), non-Hispanic Black (74.7%), and between 18 and 55 years (59.3%). The median QCCI score was 1 (range = 1-12, interquartile range = 0-2), demonstrating predominately low mortality risk. We did not establish a statistically significant association between QCCI score and VS (adjusted odds ratio = 1.06, 95% confidence interval 0.96-1.17). Our findings suggest that a higher QCCI score was not associated with lower VS in this population, which may be partly due to the high retention in care among cohort participants.

Housing, HIV outcomes, and related comorbidities in persons living with HIV in Washington, DC

Housing instability can hinder the ability of people with HIV (PWH) to maintain engagement in care, adhere to antiretroviral (ART) regimens, and achieve viral suppression. This analysis examined the association between housing instability and HIV outcomes, as well as the association between housing status and substance use disorders, mental health disorders, and sexually transmitted infections. Multivariable logistic regressions were performed using data from the DC Cohort, a longitudinal cohort of PWH. Among 8622 PWH, unstably housed PWH were significantly more likely to be prescribed ART (aOR: 1.4; 95%CI: 1.1, 1.8) yet were significantly less likely to be virally suppressed (aOR: 0.6; 95%CI: 0.5, 0.8). Unstably housed PWH were also significantly more likely to have a substance use or mental health disorder, which may inhibit PWH's ability to achieve viral suppression. Efforts to end the HIV epidemic should address housing to ensure treatment is optimized for key populations.

Characteristics and complications of anogenital infantile hemangiomas: A multicenter retrospective analysis

BACKGROUND

Infantile hemangiomas (IHs) of the anogenital region remain poorly characterized.

OBJECTIVE

To examine the distribution, ulceration rate, and associated congenital anomalies of anogenital IHs.

METHODS

Retrospective study at 8 tertiary referral centers.

RESULTS

A total of 435 infants with an IH of the anogenital region were enrolled (of which, 319 [73%] were girls). Congenital anomalies were present in 6.4% (n = 28) of infants with an anogenital IH. Segmental or partial segmental anogenital IHs ulcerated in 72% (n = 99 of 138) of infants, whereas 45% (n = 133 of 297) of focal anogenital IHs experienced ulceration (P < .001). In a multivariable logistic regression analysis, segmental or partial segmental morphology (adjusted odds ratio [aOR], 2.70; 95% CI, 1.60-4.64), mixed type (aOR, 3.44; 95% CI, 2.01-6.07), and perianal (aOR, 3.01; 95% CI, 1.53-6.12) and buttocks location (aOR, 2.08; 95% CI, 1.17-3.76) had increased odds of ulceration. Segmental or partial segmental IHs of the genitalia were confined to distinct anatomic territories and were predominantly distributed unilaterally, with a linear demarcation at the perineal raphe.

LIMITATIONS

Possible selection bias, given recruitment at tertiary referral centers.

CONCLUSION

This study improves our understanding of high-risk features of anogenital IHs and demonstrates that genital segmental or partial segmental IHs develop within distinct anatomic territories.

The prevalence and clinical significance of HER2 overexpression in prostate adenocarcinoma

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Background: The HER2 oncogene serves as a prognostic marker in breast cancer and is a therapeutic target in breast, lung, and GI malignancies, including cancers with low Her2 overexpression. A prior study by Minner et al ( Clin Cancer Res, 2010) evaluating Her2 overexpression in prostate cancer (PCa) showed a prevalence ~20%. The goal of this study is to evaluate the prevalence and clinical significance of Her2 overexpression in PCa in a predominantly African American (AA) cohort. Methods: 124 PCa patients managed at the Washington DC VA Medical Center between 2000-2021 were randomly selected: 35 indolent (AJCC stage I), 46 locally advanced (AJCC stages II&III), 19 locally advanced at diagnosis but progressed to metastatic (AJCC stage IV), and 24 de novo metastatic (AJCC stage IV). Immunohistochemistry (IHC) for Her2 was performed on one representative tissue section from core biopsies or a radical prostatectomy for each case. IHC intensity was scored independently by two experienced pathologists as negative (0, no staining), low positive (1+, faint membranous staining), moderate positive (2+, weak to moderate complete, basolateral or lateral membranous staining) or strong positive (3+, strong complete, basolateral or lateral membranous staining). Fisher’s exact test was used to test the association between Her2 expression and categorical variables. Results: 108 patients (87%) self-identified as AA. The mean age at diagnosis was 62.9 years. The prevalence of positive Her2 expression (1+, 2+,3+) was 48% (59/124) in the entire cohort, 29% (10/35) in the indolent group, 48% (22/46) in the locally advanced group, 68% (13/19) in the locally advanced group that progressed to metastatic disease, and 58% (14/24) in the de novo metastatic group ( p=0.0014). Prevalence of Her2 positive expression was 28% (10/36) in patients with a Gleason Score (GS) of 6, whereas in patients with a GS of 9 it was 78% (9/11) ( p<0.0001). Mean (non-zero) Her2 expression was highest in the de novo metastatic group (Her2 2.0, SD 0.78), followed by the locally advanced group that progressed to metastatic disease (Her2 1.54, SD 0.66), the locally advanced group without metastatic disease (Her2 1.36, SD 0.58), and lowest in the indolent group (Her2 1.0, SD 0.0) ( p=0.0016). Next generation sequencing data was available for 20 metastatic patients (12 positive for Her2 expression) and did not show the presence of HER2 mutations or amplifications. Conclusions: In this predominantly AA cohort, expression of Her2 was identified in almost 50% of patients with PCa. Her2 scores ≥2 were associated with higher GS and advanced disease. Moreover, a Her2 score of 3 was seen in 6 patients in our cohort. Historic studies on targeting Her2 in advanced PCa have failed to demonstrate clinical benefit. However, in the era of targeted therapy, Her2 inhibition addressing low-levels of Her2 overexpression should be considered in future trials.

RIPK2 as a prognostic biomarker and predictor of aggressive prostate cancer

211

Background: Receptor-Interacting Protein Kinase 2 (RIPK2) has been known to play a significant role in inflammation and anti-microbial response via the NF-KB pathway. Recently, RIPK2 was also shown to stabilize and activate c-Myc, a molecule implicated in the progression of various malignancies including prostate cancer (PCa). Our study aims to determine the prognostic value of RIPK2 expression in PCa using immunohistochemistry (IHC) analysis of biopsy specimens with special focus on a predominantly African American (AA) cohort. Methods: Eligible patients aged ≥18 years diagnosed with PCa at the Washington DC VA Medical Center were randomly selected and retrospectively grouped into indolent, locally advanced, and metastatic disease categories and stratified by age, ethnicity, AJCC stage, PSA and Gleason score at diagnosis. Representative tissue from prostate core biopsy, transurethral resection, or radical prostatectomy was analyzed for each patient. RIPK2 expression and intensity were assessed by IHC and graded by two independent pathologists by the following scale: 0 (no cytoplasmic staining), 1+ (weak cytoplasmic staining similar to benign prostatic tissue), 2+ (moderate cytoplasmic staining), and 3+ (strong cytoplasmic staining). The primary endpoint was RIPK2 expression by disease group, and key secondary outcomes were RIPK2 association with Gleason score, PSA at diagnosis, age and race. Fisher’s exact test was used to evaluate statistical significance of the association between RIPK2 expression level and disease category. Results: A total of 89 patients were selected for analysis, of which 75 (84.3%) were AA. All tumors had at least 1+ level RIPK2 expression and there was a highly significant difference in RIPK2 expression according to disease severity (p < 0.001). Stratified RIPK2 expression was 1.53, 1.83, and 2.28 in the indolent, locally advanced, and metastatic groups respectively. We observed a significant directly proportional correlation between RIPK2 expression and a higher PSA level (p= 0.0021), Gleason score (p< 0.001), higher age (p= 0.0276), and AJCC stage (p< 0.001) at the time of diagnosis. Mean RIPK2 expression was 1.81 in AA patients and 2.15 in White patients (p= 0.0332). Conclusions: PCa is the most prevalent cancer in US males and there is an urgent need for more accurate biomarkers that can predict disease severity and suggest actionable targeted therapy. In this retrospective analysis, we confirm that higher RIPK2 expression is associated with more advanced PCa. We extend these findings to a predominantly AA cohort, which may promote improvements in personalized medicine for this population at higher risk for PCa if RIPK2-targeting drugs such as Ponatinib can be utilized.

Evaluating p53 nuclear expression and prostate cancer progression in a predominantly African American cohort

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Background: Increased utilization of next-generation sequencing has revealed evidence of early TP53 alterations in localized prostate cancer (PCa), suggesting a growing clinical potential for p53 immunohistochemistry (IHC). Prior research by Harmon and Gesztes et al. (Radiology, 2021 & Scientific Reports, 2022) support the clinical utility of detecting p53 overexpression in core biopsies and radical prostatectomies (RP) to predict underlying TP53 alterations, biochemical recurrence (BCR), and metastasis. However, to date, no established consensus exists evaluating p53 “overexpression” in PCa. This study aimed to compare two fundamental approaches to assess p53 expression across various specimens with regard to PCa progression. A secondary study aim explored whether ethnic differences in p53 expression exist. Methods: This retrospective cohort study comprised 84 randomly selected PCa patients (46 metastatic; 38 non-metastatic) enrolled between 1996 – 2021 at the DC VA Medical Center. Representative sections of core biopsies (60%), RP (17%), prostate chips (7%), and metastatic deposits (16%) were examined, where (%) equals a share of the total cohort. IHC was performed on selected sections with a p53 monoclonal antibody (Biocare Medical; p53 Tumor Suppressor Protein; clone DO-7). p53 nuclear expression was manually scored according to the highest intensity (0 absent, 1+ weak, 2+ moderate, or 3+ marked) and percentage (0%, <1%, 1-5%, and >5%) of tumor cell nuclei observed in one index block per patient. All slides were reviewed by two pathologists who were blinded to clinical data. Fisher’s exact test was used to test the association between p53 positivity and categorical variables. Results: Of 84 men included, 63 (75%) self-identified as African American (AA). The median follow-up time was 6.2 years. Thirty-four patients (40%) exhibited p53 nuclear expression, of which 18 patients (21%) showed marked (3+) nuclear intensity. Notably, 11 of 18 (61%) 3+ patients displayed <5% p53 expression. All patients with >5% p53 positivity showed marked (3+) p53 staining. The presence of marked p53 staining, regardless of percentage, was found to be significantly associated with a higher Gleason score ( p=0.0002), higher PSA at the time of biopsy ( p<0.0001), BCR ( p=0.0007) and metastasis ( p<0.0001). Importantly, marked p53 staining was identified only in patients who developed metastatic disease. No significant differences were observed in marked p53 expression between AA and Caucasian men. Conclusions: In prostate cancer, marked (3+) p53 nuclear intensity (regardless of the percentage) is associated with disease progression with no observable ethnic predilection. Therefore, careful assessment of intensity is essential to avoid under-detection (when percent criteria are applied) and maximize the number of patients who may benefit from enhanced clinical interventions.

Improvements in Virologic Control Among PWH Over Time: Narrowing the Gap Between Those With and Without STIs

Using the incidence of bacterial sexually transmitted infection (STI) as a surrogate for condomless sexual behavior, we assessed the association between STI and uncontrolled HIV replication among in-care persons with HIV (PWH) enrolled in a longitudinal HIV cohort study in the District of Columbia (the DC Cohort). Although STI occurrence initially correlated with higher HIV viral load (VL), this difference became more attenuated over time (2012-2016). This was true overall and among those with the greatest number of STIs [age 18-34, men who have sex with men (MSM)]. This likely reflects gains in population-wide virologic control through improved antiretroviral therapy and access to care, which helps mitigate the risk of HIV transmission.

HIV care continuum outcomes among recently diagnosed people with HIV (PWH) in Washington, DC

The Ending the HIV Epidemic initiative aims to decrease new HIV infections and promote test-and-treat strategies. Our aims were to establish a baseline of HIV outcomes among newly diagnosed PWH in Washington, DC (DC), a 'hotspot' for the HIV epidemic. We also examined sociodemographic and clinical factors associated with retention in care (RIC), antiretroviral therapy (ART) initiation and viral suppression (VS) among newly diagnosed PWH in the DC Cohort from 2011-2016. Among 455 newly diagnosed participants, 92% were RIC at 12 months, ART was initiated in 65% at 3 months and 91% at 12 months, VS in at least 17% at 3 months and 82% at 12 months and 55% of those with VS at 12 months had sustained VS for an additional 12 months. AIDS diagnosis was associated with RIC (aOR 2.99; 1.13-2.28), ART initiation by 3 months (aOR 2.58; 1.61-4.12) and VS by 12 months (aOR4.87; 1.69-14.03). This analysis contributes to our understanding of the HIV treatment dynamics of persons with recently diagnosed HIV infection in a city with a severe HIV epidemic.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

79 EXPERIENCES OF DIRECTORS OF NURSING IN RESIDENTIAL CARE OF OLDER PEOPLE DURING COVID 19

Background

COVID-19 was a global public health crisis and deaths in the over 65 age group represented a disproportionate number of deaths in older people. In particular, nursing homes experienced clusters of infection and high mortality rates. This paper discusses experiences of care homes’ Directors of Nursing/Persons in Charge (DoN) in their preparedness, management and control of care during COVID-19.

Methods

A mixed methods approach was used (survey- n=122) and semi-structured interviews (n=20) were conducted with DoNs in private and voluntary older person care homes in the Republic of Ireland. Survey data was analysed using descriptive and inferential statistics. Interviews were analysed using Braun & Clarke's thematic analysis.

Results

DoNs demonstrated an initial challenge in protecting residents from infection and also managing infection outbreak. However, over time they experienced more effectiveness in managing infection prevention and control as demanded at the level of a pandemic. Fifty percent of respondents experienced an infection outbreak and the data does not demonstrate any significant difference in preparedness and management in care homes which had outbreaks and those who had no outbreaks. Other challenges were related to financial sustainability of their facility while 47% of DoNs were either actively seeking other work, or thinking of leaving their post. In the interviews, the DoNs spoke of persistent concerns with the well-being of the staff and residents and a constant worry about meeting regulatory requirements and ensuring adequate staff cover for residents care needs. Moreover, the DoNs spoke of the difficulties when the media sensationalized poor care leading to a reduction of public confidence in the sector.

Conclusion

The DoNs were under constant alert and although had acclimatized to high level of infection control and prevention and managing emerging issues, the strain of the pandemic remained evident. Recommendations are given related to care homes and related to system level management for future public health crisis.

29 The Surgical Trainee Personality: Selected or Shaped?

Aim

This study aims to describe the personality differences between trainees at different stages prior to and during surgical training.

Method

The Mental Muscle Diagram Indicator was distributed electronically to doctors in training in South West London. A total of 553 trainees completed the personality questionnaire. Specifically, there were general surgery specialty (n = 53), core surgical (n = 254), and foundation trainees (n = 246). 52% of trainees were female.

Results

Women scored significantly higher in the Extraversion, Sensing and Judging personality domains (p &lt; 0.0001), there were no significant differences between genders for ‘Thinking’. One-way ANOVA only showed a significant difference in the ‘Judging’ domain between grades. Tukey's test was performed showing the difference arose from FT to CST (p = 0.008). Two-way ANOVA showed an interaction between gender and grade for ‘Judging’ and as such simple main effects were performed, with alpha = 0.017 to control for type 1 errors. Significant differences were found in the Judging domain between genders during in FT (p=0.002) and CST (p=0.002), and there was no significant difference for SpRs (p=0.15).

Conclusions

This study demonstrated differences in personality types between trainee stages and gender. These differences appear to decrease as trainees progress through their training, although the cause of this is unclear.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

O-175 Failed thaw cycles (FThC) as a key performance indicator (KPI): accounting for patient diagnosis and preimplantation genetic testing (PGT)

Study question

Does the presence of a specific infertility diagnosis, in addition to PGT, impact FThC and live birth rate (LBR)?

Summary answer

Infertility diagnoses (Dx) and PGT should be taken into consideration when developing and/or evaluating FThC KPIs.

What is known already

FThC (ie, percentage of thaw procedures that failed to produce any embryos suitable for transfer) has been suggested as a KPI for laboratory competency in freezing/thawing procedures. Previous analyses showed that PGT (including testing for aneuploidy, monogenic/single gene defects, and structural chromosome rearrangements) was associated with improved proportions of FThC and LBRs. Here, we examined whether the presence of specific Dx could further impact the extent of improvement related to PGT on FThC and LBR.

Study design, size, duration

Retrospective real-world data analyses were performed using 6 years of available data from the Society for Assisted Reproductive Technology (SART) United States Registry between 2014–2019. Data analyses, including a descriptive review, focused on the following 5 Dx: diminished ovarian reserve (DOR), endometriosis (E), ovulatory dysfunction (OD), male factor (MF), and unknown factor (UF). These Dx were chosen based on the high prevalence of thaw cycles and/or historical difficulty to treat.

Participants/materials, setting, methods

A total of 9393 thaw cycles were analyzed, including the first transfer ≥12 months after retrieval, second transfer, or later transfers, given the database output limitation (fresh and frozen transfers taking place &lt;12 months combined). Fisher’s Chi Square was used to identify differences between PGT use over time, as well as FThC stratified by age and PGT status. Linear regression was used to determine test of trend over time for LBRs.

Main results and the role of chance

FThC improved for all Dx from 2014 to 2019, except for OD. PGT use increased significantly from 2014 to 2019 for all Dx (p &lt; 0.0001), with the greatest increase observed for DOR (10.40% vs 40.52%), UF (6.97% vs 36.20%), and MF (4.68% vs 28.67%). With PGT, across Dx, only DOR showed significant difference in the proportion of FThC from 2014 to 2019 (4.37% to 0.39%; p &lt; 0.0001), compared with data without PGT (1.77% to 1.60%; p = 0.8043). Patients with DOR had the highest average proportion of FThC (all years: PGT, 0.98%; non-PGT, 1.69%). Patients with UF had the lowest average proportion of FThC with PGT, followed by those with E and MF; however, over time, the proportion of FThC for these three Dx significantly changed without PGT (2014 vs 2019): UF, 1.17% vs 0.55% (p = 0.0008); E, 1.82% vs 0.55% (p = 0.0108); MF, 1.56% vs 0.64% (p &lt; 0.0001). Interestingly, OD showed no significant difference over time regardless of PGT status. LBRs for all Dx improved over time (p &lt; 0.0001), with higher LBR observed with versus without PGT (DOR, 47.13% vs 30.19%; E, 49.83% vs 40.84%; MF, 51.74 vs 43.74%; UF, 47.88% vs 41.13%; OD, 42.77% vs 39.42%). Consistent with FThC, OD showed the smallest improvement in LBR.

Limitations, reasons for caution

Lower numbers of FThC with PGT may limit interpretability. Presence of specific Dx in this dataset did not exclude other Dx. Clinics should review internal data to develop FThC KPI values. In the absence of internal data, SART data could be used as a reference, considering patient/cycle factors and confounders.

Wider implications of the findings

This is the first study evaluating the impact of specific Dxs and PGT on FThC. FThC as a KPI can guide embryo thawing performance goals and help set clinicians and patients’ expectations regarding the percentage of FThC along with a specific Dx and PGT status.

Trial registration number

Not applicable

Short Communication:Outcomes of Dual Versus Triple Antiretroviral Drug Regimens Among Virally Suppressed Adults in the DC Cohort

This study explored virological outcomes of two-drug (2DRs) and three-drug (3DRs) antiretroviral regimens in adults with HIV in the DC Cohort. We analyzed 310 treatment-experienced adults with sustained HIV RNA ≤50 copies/mL at baseline, 53 of whom switched to 2DRs and 257 continued 3DRs. Adults on 2DRs and 3DRs had similar demographics (median age 53.3 years, 76.8% cisgender male, 76.1% Black). Adults on 2DRs had more participants with ≥2 comorbidities (62.3% vs. 42.8%, p = .019), had a longer time since HIV diagnosis (median years 20.4 vs. 13.2, p = .017), and received the regimen of interest for a shorter duration (median years 1.3 vs. 3.3, p < .001) compared with adults on 3DRs. Adults receiving 2DRs had a higher, although nonsignificant, risk for virological failure (two consecutive HIV RNA ≥50 copies/mL) at 24 months follow-up than adults on 3DRs (6.7% vs. 1.7%, respectively; p = .10). Future analysis of the effectiveness of 2DRs is needed.

Outcomes from a digital cardiovascular prevention and rehabilitation programme delivered in Ireland during COVID 19

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Government of Ireland's Sláintecare Integration Fund Health Research Board, Ireland

Background & Aim

COVID 19 has accelerated the uptake and acceptance of digital health tools for the prevention and management of Cardiovascular Disease. With health systems being urged to learn from the pandemic and to reassess how they will deliver services in future, robust audit and evaluation of digital interventions are required to inform best practice.

This study aims to evaluate the clinical outcomes of a digital CVD prevention and rehabilitation programme which was established during COVID 19 to provide cardiac patients with efficient and timely access to a home-based, structured, comprehensive programme of care.

Methods

Developed and delivered by an interdisciplinary team (Nurse Prescriber, Physiotherapist, Dietitian, Cardiologist), the core components of this 12 week programme included, behavioural change support, lifestyle modification, medical risk factor management and electronic prescribing of cardio-protective medication. To support self-management, patients were provided with a Fitbit, blood pressure monitor and a workbook to support goal setting and overall tracking of progress. Patients were given access to a bespoke web-based platform and invited to attend weekly (2hr) group-based sessions, which included an exercise component and an interactive educational workshop.

Results

Over a 4 month period, 105 patients were referred with an uptake rate of 73% (n=77). Of these, 97% (n=75) enrolled in the programme, with an 85% (n=64) completion rate. Significant improvements in CVD risk factors were observed between initial and end of programme assessment. The proportion of patients meeting guideline-recommended physical activity targets increased from 14 to 82% (p<0.001), mean BMI (kg/m2) reduced from 28.7 to 27.7 (p<0.001), mean Mediterranean diet score improved from 5.2 to 7.3 (p<0.001), and anxiety and depression levels ≥8 (Hospital Anxiety and Depression score) both reduced by more than 50% (p<0.001). The proportions achieving the recommended blood pressure (<130/80 mmHg) and LDL cholesterol targets (<1.4 mmol/L) increased from 24 to 68% (p<0.001) and 14 to 41% (p<0.001), respectively.

Conclusion

Outcomes from this programme demonstrate that digital CVD prevention and rehabilitation programmes can achieve the recommended lifestyle, medical and therapeutic targets associated with reduced CVD events and improved health outcomes. This programme represents a scalable, accessible and effective option to deliver vital CVD preventive care in the patient’s home.

Identifying geographic areas of Washington DC with increased potential for sexual HIV transmission among People with HIV with STIs and concurrent elevated HIV RNA: Data from the DC Cohort

Background

The U=U (Undetectable=Untransmittable) campaign advances the goal of ending the HIV epidemic by promoting durable viral suppression and therefore reducing sexual transmission. We used geospatial analysis to assess the potential for sexual HIV transmission by ZIP code of residence in the District of Columbia (DC) using data from DC Cohort Longitudinal HIV Study (DC Cohort), a city-wide cohort of persons with HIV (PWH).

Methods

DC Cohort participants ages ≥13 were included in the study period between April 1, 2016 and March 31, 2018. Potential for sexual HIV transmission was defined as the proportion of participants with incident sexually transmitted infection (STI - gonorrhea, chlamydia, syphilis) and with HIV RNA ≥200 copies/mL from 9 months prior to 3 months after STI diagnosis. We performed geographic information system (GIS) analysis to determine the ZIP codes with the highest potential for sexual HIV transmission.

Results

Of 3,467 participants, 367 (10.6%) had at least one incident STI, with 89.4% residing in 11 of the 20 residential ZIP codes in DC. Of the 367 participants with an incident STI, at least one HIV RNA was available for 348 (94.8%). 97 (27.9%) of individuals with an incident STI had HIV RNA ≥200 copies/ml in the defined time window. Of these 97, 66 (68.0%) resided in 5 of the 20 DC ZIP codes.

Conclusions

In DC, 5 ZIP codes of residence accounted for the majority of the estimated potential for HIV transmission among participants in the DC Cohort. These results support focused neighborhood-level interventions to help end the HIV epidemic.

What motivates students to decrease or cease substance use?: A scoping review

OBJECTIVE

The association between illicit substance use by third-level education students and their mental and physical health is well documented. The aim of this scoping review was to determine factors that contribute to student motivations to reduce or stop their use of illicit substances, and to elaborate on factors that may be pertinent for student-focused behaviour change interventions for substance use.

METHOD

We searched eight databases in March 2021 using search terms based on 'students', 'illicit substance use', and 'motivations'. We identified 86 research articles that reported on third-level education students' illicit substance use and included reasons or motives for their use.

RESULTS

After full-text screening, three studies were eligible for inclusion in the qualitative synthesis. The majority of studies described motives for abstention but did not describe motivation for reducing or stopping current patterns of use of illicit substances.

CONCLUSION

Few studies have examined motivations of third-level education students to decrease or cease substance use. Promising avenues for research on motivations to change substance use behaviour include the social contextual factors, perceived effects on social relationships, and actions of friends and family to prompt contemplations of change.

A113 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN PATIENTS WITH SURGICALLY ALTERED ANATOMY IN A CANADIAN TERTIARY REFERRAL CENTRE

Background

Endoscopic retrograde cholangiopancreatography (ERCP) has become a mainstay of diagnosis and treatment of pancreatobiliary conditions. Surgically altered anatomy presents unique challenges in the procedure, necessitating creative solutions such as different types of endoscopes and tools. Distinct from regular anatomy, forward viewing scopes are often required for successful cannulation and therapy of the pancreaticobiliary system. To our knowledge, there is limited data on the practice of ERCP in altered anatomy in Canada.

Aims

Our aim is to present outcomes from a large series of patients with surgically altered anatomy who underwent ERCP at a large Canadian referral centre.

Methods

All ERCP procedures at a tertiary referral centre in Vancouver, Canada from Oct 2020 to Oct 2021 were reviewed retrospectively. Inclusion criteria required surgically altered anatomy and attempted ERCP. Liver transplant patients with duct-to-duct anastomosis were not included in the series. Patients with incomplete procedure documentation were excluded. Demographic, procedural and outcome data were collected. Results are presented descriptively and as median + IQR for quantitative data. Procedural success was defined as cannulation and performance of a cholangiogram and/or pancreatogram

Results

A total of 34 procedures met the inclusion criteria during the study period. Twenty-four procedures were on male patients (71%). Nineteen patients (56%) had had previous ERCP. Sixteen patients (47%) had choledocholithasis as the indication for the procedure, 9 patients (26%) had cholangitis and 5 patients (15%) had concerns of neoplasia. Some patients had multiple indications. Seventeen patients (50%) had roux-en-Y anatomy, 8 patients (24%) were post Whipple’s and 6 patients (18%) had Billroth II type anatomy. Other altered anatomy included duodenal switch, and post gastrojejunostomy bypass. The most commonly used endoscope was the adult or pediatric colonoscope (74% of cases). Single balloon enteroscope was used in 5 cases (15%). Overall success rate was 74%. The breakdown of success rate by anatomy is shown in Table 1. One (3%) complication was noted in the form of mild cholangitis, requiring only outpatient antibiotics.

Conclusions

Experience in ERCP in patients with altered anatomy is becoming more pertinent in tertiary care. Cannulation and therapy is more difficult in this cohort, but still successful in the majority of cases. Adverse events remain uncommon. Knowledge of forward viewing ERCP techniques is critical in surgically altered anatomy. Future studies will aim to expand the retrospective cohort for more quantitative analysis.

Funding Agencies

None

In Vivo Reflectance Confocal Microscopy of Cutaneous Acute Graft-Versus-Host Disease: Concordance with Histopathology and Interobserver Reproducibility of a Glossary with Representative Images

BACKGROUND

The reliability to noninvasively identify features of inflammatory dermatoses by reflectance confocal microscopy (RCM) remains unknown. Lack of formal training among RCM readers can result in inconsistent assessments, limiting clinical utility. Specific consensus terminology with representative images is necessary to ensure consistent feature-level interpretation among RCM readers.

OBJECTIVES

(1) Develop a glossary with representative images of RCM features of cutaneous acute graft-versus-host disease (aGVHD) for consistent interpretation among observers, (2) assess the interobserver reproducibility among RCM readers using the glossary, and (3) determine the concordance between RCM and histopathology for aGVHD features.

METHODS

Through an iterative process of refinement and discussion among five international RCM experts, we developed a glossary with representative images of RCM features of aGVHD. From April to November 2018, patients suspected of aGVHD were imaged with RCM and subsequently biopsied. 17 lesions from 12 patients had clinically and pathologically confirmed cutaneous aGVHD. For each of these lesions, four dermatopathologists and four RCM readers independently evaluated the presence of aGVHD features in scanned histopathology slides and 1.5x1.5 mm RCM submosaics at 4 depths (blockstacks), respectively. RCM cases were adjudicated by a fifth RCM expert. Interobserver reproducibility was calculated by U statistic. Concordance between modalities was determined by fraction agreement.

RESULTS

We present a glossary with representative images of 18 aGVHD features by RCM. The average interobserver reproducibility among RCM readers (75%, confidence interval, CI: 71%-79%) did not differ significantly from dermatopathologists (80%, 76%-85%). The concordance between RCM and histopathology was 59%.

CONCLUSIONS

By using the glossary, the interobserver reproducibility among RCM readers was similar to the interobserver reproducibility among dermatopathologists. There was good concordance between RCM and histopathology to visualize aGVHD features. The implementation of RCM can now be advanced in a variety of inflammatory conditions with a validated glossary and representative image set.

Signatures of natural selection in a foundation tree along Mediterranean climatic gradients

Temperature and precipitation regimes are rapidly changing, resulting in forest dieback and extinction events, particularly in Mediterranean‐type climates (MTC). Forest management that enhance forests’ resilience is urgently required, however adaptation to climates in heterogeneous landscapes with multiple selection pressures is complex. For widespread trees in MTC we hypothesized that: patterns of local adaptation are associated with climate; precipitation is a stronger factor of adaptation than temperature; functionally related genes show similar signatures of adaptation; and adaptive variants are independently sorting across the landscape. We sampled 28 populations across the geographic distribution of Eucalyptus marginata (jarrah), in South‐west Western Australia, and obtained 13,534 independent single nucleotide polymorphic (SNP) markers across the genome. Three genotype‐association analyses that employ different ways of correcting population structure were used to identify putatively adapted SNPs associated with independent climate variables. While overall levels of population differentiation were low (F_ST = 0.04), environmental association analyses found a total of 2336 unique SNPs associated with temperature and precipitation variables, with 1440 SNPs annotated to genic regions. Considerable allelic turnover was identified for SNPs associated with temperature seasonality and mean precipitation of the warmest quarter, suggesting that both temperature and precipitation are important factors in adaptation. SNPs with similar gene functions had analogous allelic turnover along climate gradients, while SNPs among temperature and precipitation variables had uncorrelated patterns of adaptation. These contrasting patterns provide evidence that there may be standing genomic variation adapted to current climate gradients, providing the basis for adaptive management strategies to bolster forest resilience in the future.

COVID-19: Identifying and addressing determinants of adherence to physical distancing guidance

Background

Optimising physical distancing measures has been a critical part of the global response to the spread of COVID-19. Adherence to these recommendations has been poorer than adherence to other key transmission reduction behaviours. The current project aimed to identify psychosocial determinants of adherence to physical distancing, and to determine whether Government of Ireland COVID-19 communications adequately address the determinants.

Methods

A nationally representative cross-sectional survey as part of the International COVID-19 Awareness and Responses Evaluation (iCARE) study, a qualitative interview study, and a content analysis of COVID-19 poster communications were conducted to identify psychosocial determinants of adherence and determine the extent to which these were addressed in government communications.

Results

The iCARE survey showed adherence to physical distancing measures varies by sociodemographic group (e.g., age, sex, COVID-19 risk category) and beliefs. Poorest adherence was reported by younger people, males, those at lower risk of serious illness from COVID-19, and those who were less concerned about the impact of COVID-19 on public health and the economy. The qualitative interview study revealed maintaining and negotiating close relationships, public physical environments, habituation to threat, risk-taking to maintain wellbeing, and confusion and uncertainty around government guidelines as barriers to physical distancing behaviour. Having a sense of personal responsibility and control over one's own behaviour was identified as a potential facilitator of adherence to distancing. Content analysis revealed some important gaps, particularly in terms of rationale for specific public health guidelines.

Conclusions

Though adherence was high overall, there was variability among sociodemographic groups. Government communications to promote physical distancing could be refined to better address key barriers and facilitators of the behaviour.

1627 We Are Donors: Redeveloping Educational Material for Schools in Response To COVID-19

Aim

We Are Donors is a UK registered charity aiming to increase the number of organ and blood donors across the UK through student led education at schools and universities. Over the last two years we have spoken to over 4000 students and have shown that the program improves awareness of organ donation, facilitates discussion within families and increases the number of planned organ donor registry sign ups. In response to COVID-19 our educational sessions moved online, and we studied what impact this had on engagement with the students and how our material could be redeveloped to improve outcomes.

Method

We compared the feedback from 1514 children aged 11-18 years who received face to face presentations in August 2018 - May 2019 with that from a group of 141 children aged 14 -18 years from 5 schools who received live online sessions using the same powerpoint presentation between March 2020 - June 2020.

Results

The change to online delivery reduced recommendation of the talk to a friend from 88% to 69%. Moving to online sessions also resulted in reduced post session feedback. To tackle these issues, we re-developed our presentation in collaboration with Slido to feature interactive elements, a quiz (including a leaderboard) and a real-time question and answer session. We also incorporated an immediate feedback survey.

Conclusions

Our study highlights new challenges that educators are facing when moving to online platforms. While moving online allows more students to be reached, maintaining high levels of student engagement is challenging.

Exploring the costs associated with isotretinoin treatment

The multistep process to obtain an isotretinoin prescription under the iPLEDGE program is challenging for patients, particularly female patients. This retrospective study evaluates the differences in treatment and costs between male and female patients. While male patients had a higher total cost of treatment than female patients, female patients had a higher treatment cost when medication costs were excluded. Female patients who missed prescription windows had a longer treatment course and incurred significantly higher treatment costs than female patients who did not miss a prescription window. The iPLEDGE program places female patients at a disadvantage of incurring higher treatment costs as a consequence of the prescription window requirement.

What am I doing here? Enablers and barriers to community-based cardiac rehabilitation attendance: a qualitative study utilising a behavioural science approach

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Community Engaged Scholars Programme (CES-P), PPI Ignite, National University of Ireland, Galway

Background

Despite the well-established benefits of cardiovascular prevention and rehabilitation, programme uptake rates remain suboptimal. Delivering cardiac rehabilitation (CR) in the community offers an alternative model of care that may help address the challenges that exist around uptake and accessibility of CR. Yet in comparison to traditional hospital based CR programmes less is known about the enablers and barriers that may be unique to attending community based CR programmes.

Purpose

This study aimed to identify enablers and barriers to attending and completing a community-based CR programme from the patient perspective.

Methods

Individuals who were referred to a 12 week, interdisciplinary, multi-component community-based CR programme were invited to take part in semi-structured interviews. Reasons for attending or not attending the programme and for completing or not completing the full programme were discussed. Purposeful sampling was used to obtain variation in age, gender, and level of engagement with the programme. Interviews were transcribed verbatim and analysed using framework analysis guided by the Capability Opportunity Motivation (COM B) Model and the Theoretical Domains Framework, to explore initial attendance and programme completion.

Results

Data saturation was achieved with sixteen participants. The majority of the identified barriers and enablers were common to both initial programme attendance and completion of programme. Having the social opportunity to receive support from peers, family members and staff was seen as an important enabler. While ease of access to a programme based in the community enabled attendance and completion, for some, distance to the cardiac rehabilitation centre was a barrier. Further barriers related to capability issues regarding poor physical health, time, work commitments and travel. Key motivational enablers included, beliefs around consequences, improved health status, knowledge, goals, intentions and personality. Identity was an important determinant of attendance as participants discussed their understanding of "what am I doing here?" Some participants identified themselves as the type of person who would benefit from the programme and others did not. For example, some felt the programme would suit those who needed motivation to enhance their health and some felt the programme was more or less suited to people of different ages and fitness levels.

Conclusion

The results suggest that interventions to enhance attendance at community-based CR need to address multiple factors related to capability, opportunity and motivation. While there is no one model of cardiovascular prevention and rehabilitation that will meet the needs of all patients, patients should be offered community based programmes as part of a choice of options that fit their needs and personal preferences.

Trajectories of fatigue in a population-based sample of older adult breast, prostate, and colorectal cancer survivors: an analysis using the SEER-MHOS data resource

PURPOSE

Fatigue is one of the most common and distressing symptoms experienced by cancer survivors. Understanding fatigue trajectories from pre- to post-diagnosis could inform fatigue prevention and management strategies.

METHODS

We used the Surveillance, Epidemiology and End Results Medicare Health Outcomes Survey (SEER-MHOS) linked data resource to characterize fatigue trajectories and their predictors 1214 older adult survivors of breast, colorectal, or prostate cancer. Fatigue was measured prior to the cancer diagnosis (T0) and at two timepoints after diagnosis (T1: mean = 20 months and T2: mean = 39 months post-diagnosis). Latent growth curve modeling and mixed effects models for repeated measurements were used to investigate fatigue experiences before and after a cancer diagnosis.

RESULTS

Overall, mean fatigue T-scores declined (T0 = 50, T1 = 46, and T2 = 45) indicating worsening fatigue over time. Four latent trajectory subgroups were identified: severe fatigue worsening over time (8.2% of sample), severe fatigue persisting over time (14.4%), no fatigue pre-diagnosis and mild fatigue post-diagnosis (44.4%), and not fatigued (33%). Age, cancer stage, comorbidities, and depressed mood predicted membership in the two trajectory groups experiencing severe fatigue that persisted or that worsened post-diagnosis. Older age, advanced cancer stage at diagnosis, and depressed mood were significantly associated with worsening fatigue from T1 to T2 (all p < 0.0001).

CONCLUSIONS

Evaluating cancer patients for depressive symptoms and considering prior fatigue levels, age, comorbid conditions, and cancer stage may help providers anticipate fatigue trajectories and implement pre-emptive strategies to lessen fatigue impact.

986 A Systematic Review of Medical Student Willingness to Volunteer and Preparedness for Pandemics and Disasters

Introduction

We aimed to identify motivators and barriers to volunteering during a disaster and knowledge and medical school curriculum of disaster and pandemic medicine.

Method

We systematically searched the literature on 28/6/2020, following PRISMA guidelines.

Results

A total of 37 studies met inclusion criteria including 11,168 medical students and 91 medical schools. 24 studies evaluated knowledge (64.9%), 16 evaluated volunteering (43.2%), and five evaluated medical school curricula (13.5%). Weighted mean willingness to volunteer during a disaster was 68.4% (SD = 21.7%, n = 2911), and there was a significant difference between those planning to volunteer and those who actually volunteered (P<.001). We identified a number of modifiable barriers which may contribute to this difference. Overall, knowledge of disasters was poor with a weighted mean of 48.9% (SD = 15.1%, n = 2985).

Conclusions

There is a large number of students who are willing to volunteer during pandemics. However, they are likely to be under-prepared for these roles due to poor overall knowledge and limited teaching. During the current COVID-19 pandemic and in future disasters, medical students may be required to volunteer as auxiliary staff. Medical schools need to develop infrastructure to facilitate this process as well as providing education and training to ensure students are adequately prepared for these roles.

967 COVID READY Study: Cross-Sectional Survey of Medical Students Volunteering During the Coronavirus Pandemic (COVID-19) In the United Kingdom

Introduction

We aimed to identify the willingness, attitudes, and practice of medical students towards volunteering in a clinical capacity during the COVID-19 pandemic.

Method

We distributed a cross-sectional survey from 2/5/2020 to 14/6/2020 to all medical students at UK medical schools.

Results

A total of 1145 medical students from 36 medical schools completed the questionnaire. 82.7% of students were willing to volunteer, but only 34.3% had volunteered. The strongest predictors of willingness to volunteer on multiple linear regression were the beliefs that volunteering to work would benefit their medical education (estimate=0.35±0.03, adjusted P < 0.001) and that they would have a positive impact (estimate=0.33±0.03, adjusted P < 0.001). The majority of students were willing to take up a clinical role and were confident in having the necessary skills, but there was a discrepancy between the role’s students were comfortable performing and those they were assigned. Thematic analysis of the issue’s students would face when volunteering identified five themes: safety, professional practice, pressure to volunteer, finances and logistics, and education.

Conclusions

This study identifies areas for consideration from those responsible for workforce planning, healthcare provision, and student safety. We provide recommendations to facilitate a volunteering process that is safer for students, staff, and patients.

Utilization of Direct Oral Anticoagulants in People Living with Human Immunodeficiency Virus: Observational Data from the District of Columbia Cohort

BACKGROUND

Direct oral anticoagulants (DOACs) have become first-line treatment for venous thrombotic events. DOAC prescribing trends among people living with human immunodeficiency virus (PWH) are not well described. The coadministration of DOACs with the antiretroviral (ARV) pharmacokinetic boosters ritonavir (RTV) or cobicistat (COBI) may be complicated by pharmacokinetic interactions.

METHODS

A longitudinal cohort study was conducted using the D.C. Cohort Database in Washington, D.C., from January 2011 to March 2017, to describe oral anticoagulant prescribing among PWH ≥ 18 years old and the prevalence of DOAC use with RTV or COBI. Data collection included demographic and clinical characteristics, ARV and anticoagulant prescriptions, and International Classification of Diseases Ninth and Tenth Edition diagnosis codes.

RESULTS

Among 8315 PWH, there were 236 anticoagulant prescriptions (96 DOAC, 140 warfarin) for 206 persons. PWH prescribed anticoagulants were predominantly Black (82%) and male (82%), with a mean age at anticoagulant initiation of 56 years. DOAC use increased from 3% of total anticoagulant prescribing in 2011 to 43% in 2016, accounting for 64% of all newly recorded anticoagulant prescriptions by 2016. There were 19 bleeding events recorded among 16 individuals. Despite the Food and Drug Administration label recommendation to avoid rivaroxaban with boosted ARVs, 41% remained on boosted ARVs after rivaroxaban initiation.

CONCLUSIONS

DOAC use increased substantially in PWH by 2016. Although rivaroxaban is not recommended with RTV or COBI, concomitant use was recorded in 41% of rivaroxaban recipients in this cohort. As DOAC usage increases, clinicians need to be aware of potential DOAC/ARV interactions in order to select the most appropriate oral anticoagulant and monitoring plan for PWH.

Examining Retention in HIV Care and HIV Suppression on Housing Services Intake at a Washington, DC Community Based Organization

In Washington, DC, 2% of residents are living with HIV, with 15.3% of them experiencing homelessness. Additionally, over half of DC-area renters are paying over 30% of their income for housing. The primary objective of this study was to describe HIV outcomes at initial intake at Housing Counseling Services (HCS). This retrospective study included adults with HIV completing HCS intake between 2015 and 2018 and linked HCS data with DC Department of Health (DOH) HIV/AIDS, Hepatitis, STD, and TB Administration (HAHSTA) surveillance data. Proportions of individuals with retention in care (RIC) and viral suppression (VS) were compared across client subgroups using chi-square or rank sum tests. The sample of 734 participants was mostly male (67%), Non-Hispanic Black (89%), had MSM as the HIV transmission risk factor (44%) and had rental housing (60%). Most participants (634/734, 86%) were RIC at HCS intake. A majority of participants (477/621 or 77%) had VS at intake. Older age was associated with VS (p = 0.0007). Homeless individuals (with intake from the street) were less likely to be VS (4.8% vs. 11.1%, p < 0.0045). Our results suggest that PWH who have unstable housing or who are homeless may need additional support services for maintaining RIC and VS, as the proportion meeting those benchmarks was not at goal when they sought services at HCS.

Landscape and taxon age are associated with differing patterns of hybridization in two Eucalyptus (Myrtaceae) subgenera

BACKGROUND AND AIMS

Hybridization is an important evolutionary process that can have a significant impact on natural plant populations. Eucalyptus species are well known for weak reproductive barriers and extensive hybridization within subgenera, but there is little knowledge of whether patterns of hybridization differ among subgenera. Here, we examine eucalypts of Western Australia's Stirling Range to investigate how patterns of hybridization are associated with landscape and taxon age between the two largest Eucalyptus subgenera: Eucalyptus and Symphyomyrtus. In doing so, we tested a hypothesis of OCBIL (old, climatically buffered, infertile landscape) theory that predicts reduced hybridization on older landscapes.

METHODS

Single nucleotide polymorphism markers were applied to confirm the hybrid status, parentage and genetic structure of five suspected hybrid combinations for subg. Eucalyptus and three combinations for subg. Symphyomyrtus.

KEY RESULTS

Evidence of hybridization was found in all combinations, and parental taxa were identified for most combinations. The older parental taxa assessed within subg. Eucalyptus, which are widespread on old landscapes, were identified as well-defined genetic entities and all hybrids were exclusively F1 hybrids. In addition, many combinations showed evidence of clonality, suggesting that the large number of hybrids recorded from some combinations is the result of long-term clonal spread following a few hybridization events rather than frequent hybridization. In contrast, the species in subg. Symphyomyrtus, which typically occur on younger landscapes and are more recently evolved, showed less distinction among parental taxa, and where hybridization was detected, there were high levels of introgression.

CONCLUSIONS

Reduced hybridization in subg. Eucalyptus relative to extensive hybridization in subg. Symphyomyrtus affirmed the hypothesis of reduced hybridization on OCBILs and demonstrate that clade divergence times, landscape age and clonality are important drivers of differing patterns of speciation and hybridization in Eucalyptus.

Transition from child to adult health services for young people with cerebral palsy in Ireland: a mixed-methods study protocol

INTRODUCTION

The transition from child to adult health services is a challenging and complex process for young people with cerebral palsy (CP). Poorly managed transition is associated with deterioration in health, increased hospitalisations and reduced quality of life. While international research identifies key practices that can improve the experience and outcomes of transition, there is a paucity of data in the Irish context. This research study aims to gain an insight into the experience of transition for young people with CP in Ireland.

METHODS AND ANALYSIS

A convergent parallel mixed-methods design will be used to collect, analyse and interpret quantitative and qualitative data. Participants will be young people aged 16-22 years with CP, their parent(s)/carer(s) and service providers. Quantitative and qualitative data will be collected through questionnaires and interviews, respectively. Quantitative data will be reported using descriptive statistics. Where sufficient data are collected, we will examine associations between the experience of transition practices and sociodemographic and CP-related factors, respectively, using appropriate regression models. Associations between service provider characteristics and provision of key transition practices may also be explored using appropriate regression models. Qualitative data will be analysed using the Framework Method. A coding matrix based on key transitional practices identified from the literature will be used to identify convergence and divergence across study components at the integration stage.

ETHICS AND DISSEMINATION

The study has been approved by the RCSI University of Medicine and Health Sciences Research Ethics Committee (REC201911010). Results will be presented to non-academic stakeholders through a variety of knowledge translation activities. Results will be published in open access, peer-reviewed journals and presented at national and international scientific conferences.

Sexual Risk Behaviors Associated with Sexually Transmitted Infections in a US Military Population Living with HIV After the Repeal of "Don't Ask, Don't Tell"

Risk behaviors associated with sexually transmitted infections (STIs) among people living with HIV (PLWH) have not been well characterized in the US military. We identified risk behaviors associated with a new STI in this population after the repeal of "Don't Ask, Don't Tell." US Military HIV Natural History Study participants who completed the risk behavior questionnaire (RBQ) between 2014 and 2017 and had at least 1 year of follow-up were included (n = 1589). Logistic regression identified behaviors associated with incident STI in the year following RBQ completion. Overall, 18.9% acquired an STI and 52.7% reported condom use at last sexual encounter. Compared with those with no new sex partners, participants with between one and four or five or more new partners were 1.71 [1.25-2.35] and 6.12 [3.47-10.79] times more likely to get an STI, respectively. Individuals reporting low or medium/high perceived risk of STI were 1.83 [1.23-2.72] and 2.65 [1.70-4.15] times more likely to acquire a new STI than those reporting no perceived risk, respectively. Participants who preferred not to answer about sexual preference, number of new partners, or perceived STI risk were also more likely to acquire a new STI. Our study illustrates that despite regular access to health care and accurate perceptions of risk, rates of STI among PLWH remain high in the US military setting, as in others. Given the potential individual and public health consequences of STI coinfection after HIV, more work is needed to assess interventions aimed at sexual behavior change for PLWH.

Improving Outcomes Among Young Adults with type 1 diabetes: The D1 Now Randomised Pilot Study Protocol

BACKGROUND

Young adults (18-25 years old) living with type 1 diabetes mellitus often have sub-optimal glycaemic levels which can increase their risk of long term diabetes complications. Informed by health psychology theory and using a (public and patient involvement) young adult-centred approach, we have developed a complex intervention, entitled D1 Now, to improve outcomes in this target group. The D1 Now intervention includes three components; 1) a support-worker, 2) an interactive messaging system and 3) an agenda setting tool for use during clinic consultations.

AIMS

The aim of the D1 Now pilot study is to gather and analyse acceptability and feasibility data to allow us to (1) refine the D1 Now intervention, and (2) determine the feasibility of a definitive Randomised Control Trial (RCT) of the intervention.

METHODS

Diabetes clinics on the island of Ireland will be recruited and randomised to a D1 Now intervention arm or a usual care control arm. For a participant to be eligible they should be 18-25 years old and living with type 1 diabetes for at least 12 months. Participant outcomes (influenced by a Core Outcome Set) include change in HbA1c, clinic attendance, number of episodes of severe hypoglycaemia and of diabetic ketoacidosis, diabetes distress, self-management, quality of life and perceived level of control over diabetes; these will be will be measured at baseline and after 12 months follow-up for descriptive statistics only. An assessment of treatment fidelity, a health economic analysis and a qualitative sub-study will also be incorporated into the pilot study. ISRCTN (ref: ISRCTN74114336).

The US Military HIV Natural History Study: Informing Military HIV Care and Policy for Over 30 Years

INTRODUCTION

In October 1985, 4 years after the initial descriptions of the acquired immunodeficiency syndrome (AIDS), the U.S. Department of Defense (DoD) began routine screening for human immunodeficiency virus (HIV) infection to prevent infected recruits from exposure to live virus vaccines, implemented routine active-duty force screening to ensure timely care and help protect the walking blood bank, and initiated the U.S. Military HIV Natural History Study (NHS) to develop epidemiologic, clinical, and basic science evidence to inform military HIV policy and establish a repository of data and specimens for future research. Here, we have reviewed accomplishments of the NHS over the past 30 years and sought to describe relevant trends among NHS subjects over this time, with emphasis on combination antiretroviral therapy (cART) use and non-AIDS comorbidities.

METHODS

Subjects who were prospectively enrolled in the NHS from 1986 through 2015 were included in this analysis. Time periods were classified by decade of study conduct, 1986-1995, 1996-2005, and 2006-2015, which also correlate approximately with pre-, early-, and late-combination ART (cART) eras. Analyses included descriptive statistics and comparisons among decades. We also evaluated mean community log10 HIV viral load (CVL) and CD4 counts for each year.

RESULTS

A total of 5,758 subjects were enrolled between 1986 and 2015, of whom 92% were male with a median age of 28 years, and 45% were African-American, 42% Caucasian, and 13% Hispanic/other. The proportion of African-Americans remained stable over the decades (45%, 47%, and 42%, respectively), while the proportion of Hispanic/other increased (10%, 13%, and 24%, respectively). The CD4 count at HIV diagnosis has remained high (median 496 cells/uL), while the occurrence of AIDS-defining conditions (excluding low CD4 count) has decreased by decade (36.7%, 5.4%, and 2.9%, respectively). Following the introduction of effective cART in 1996, CVL declined through 2000 as use increased and then plateaued until guidelines changed. After 2004, cART use again increased and CVL declined further until 2012-15 when the vast majority of subjects achieved viral suppression. Non-AIDS comorbidities have remained common, with approximately half of subjects experiencing one or more new diagnoses overall and nearly half of subjects diagnosed between 2006 and 2015, in spite of their relatively young age, shorter median follow-up, and wide use of cART.

CONCLUSIONS

The US Military HIV NHS has been critical to understanding the impact of HIV infection among active-duty service members and military beneficiaries, as well as producing insights that are broadly relevant. In addition, the rich repository of NHS data and specimens serves as a resource to investigators in the DoD, NIH, and academic community, markedly increasing scientific yield and identifying novel associations. Looking forward, the NHS remains relevant to understanding host factor correlates of virologic and immunologic control, biologic pathways of HIV pathogenesis, causes and consequences of residual inflammation in spite of effective cART, identifying predictors of and potential approaches to mitigation of excess non-AIDS comorbidities, and helping to understand the latent reservoir.