User-Centered Design of a Preference-Driven Patient Activation Tool for Optimizing Depression Treatment in Integrated Primary Care Settings (The Transform DepCare Study)

BACKGROUND

Few patient engagement tools incorporate the complex patient experiences, contexts, and workflows that limit depression treatment implementation.

OBJECTIVE

Describe a user-centered design (UCD) process for operationalizing a preference-driven patient activation tool.

DESIGN

Informed by UCD and behavior change/implementation science principles, we designed a preference-driven patient activation prototype for engaging patients in depression treatment. We conducted three usability cycles using different recruitment/implementation approaches: near live/live testing in primary care waiting rooms (V1-2) and lab-based think aloud testing (V3) oversampling older, low-literacy, and Spanish-speaking patients in the community and via EHR algorithms. We elicited clinician and "heuristic" expert input.

MAIN MEASURES

We administered the system usability scale (SUS) all three cycles and pre-post V3, the patient activation measure, decisional conflict scale, and depression treatment barriers. We employed descriptive statistics and thematically analyzed observer notes and transcripts for usability constructs.

RESULTS

Overall, 43 patients, 3 clinicians, and 5 heuristic (a usability engineering method for identifying usability problems) experts participated. Among patients, 41.9% were ≥ 65 years old, 79.1% female, 23.3% Black, 62.8% Hispanic, and 55.8% Spanish-speaking and 46.5% had ≤ high school education. We described V1-3 usability (67.2, 77.3, 81.8), treatment seeking (92.3%, 87.5%, 92.9%), likelihood/comfort discussing with clinician (76.9%, 87.5%, 100.0%), and pre vs. post decisional conflict (23.7 vs. 15.2), treatment awareness (71.4% vs. 92.9%), interest in antidepressants (7.1% vs. 14.3%), and patient activation (66.8 vs. 70.9), with fewer barriers pertaining to cost/insurance, access/coordination, and self-efficacy/stigma/treatment efficacy. Key themes included digital literacy, understandability, high acceptability for aesthetics, high usefulness of patient/clinician videos, and workflow limitations. We adapted manual entry/visibility/content; added patient activation and a personalized algorithm; and proposed flexible, care manager delivery leveraging clinic screening protocols.

DISCUSSION

We provide an example of leveraging UCD to design/adapt a real-world, patient experience and workflow-aligned patient activation tool in diverse populations.

RLSuite: An Integrative R-Loop Bioinformatics Framework

We recently described the development of a database of 810 R-loop mapping datasets and used this data to conduct a meta-analysis of R-loops. R-loops are three-stranded nucleic acid structures containing RNA:DNA hybrids and we were able to verify that 30% of expressed genes have an associated R-loop in a location conserved manner.. Moreover, intergenic R-loops map to enhancers, super enhancers and with TAD domain boundaries. This work demonstrated that R-loop mapping via high-throughput sequencing can reveal novel insight into R-loop biology, however the analysis and quality control of these data is a non-trivial task for which few bioinformatic tools exist. Herein we describe RLSuite, an integrative R-loop bioinformatics framework for pre-processing, quality control, and downstream analysis of R-loop mapping data. RLSuite enables users to compare their data to hundreds of public datasets and generate a user-friendly analysis report for sharing with non-bioinformatician colleagues. Taken together, RLSuite is a novel analysis framework that should greatly benefit the emerging R-loop bioinformatics community in a rapidly expanding aspect of epigenetic control that is still poorly understood.

Integrating Clinical Decision Support Into Electronic Health Record Systems Using a Novel Platform (EvidencePoint): Developmental Study

BACKGROUND

Through our work, we have demonstrated how clinical decision support (CDS) tools integrated into the electronic health record (EHR) assist providers in adopting evidence-based practices. This requires confronting technical challenges that result from relying on the EHR as the foundation for tool development; for example, the individual CDS tools need to be built independently for each different EHR.

OBJECTIVE

The objective of our research was to build and implement an EHR-agnostic platform for integrating CDS tools, which would remove the technical constraints inherent in relying on the EHR as the foundation and enable a single set of CDS tools that can work with any EHR.

METHODS

We developed EvidencePoint, a novel, cloud-based, EHR-agnostic CDS platform, and we will describe the development of EvidencePoint and the deployment of its initial CDS tools, which include EHR-integrated applications for clinical use cases such as prediction of hospitalization survival for patients with COVID-19, venous thromboembolism prophylaxis, and pulmonary embolism diagnosis.

RESULTS

The results below highlight the adoption of the CDS tools, the International Medical Prevention Registry on Venous Thromboembolism-D-Dimer, the Wells' criteria, and the Northwell COVID-19 Survival (NOCOS), following development, usability testing, and implementation. The International Medical Prevention Registry on Venous Thromboembolism-D-Dimer CDS was used in 5249 patients at the 2 clinical intervention sites. The intervention group tool adoption was 77.8% (4083/5249 possible uses). For the NOCOS tool, which was designed to assist with triaging patients with COVID-19 for hospital admission in the event of constrained hospital resources, the worst-case resourcing scenario never materialized and triaging was never required. As a result, the NOCOS tool was not frequently used, though the EvidencePoint platform's flexibility and customizability enabled the tool to be developed and deployed rapidly under the emergency conditions of the pandemic. Adoption rates for the Wells' criteria tool will be reported in a future publication.

CONCLUSIONS

The EvidencePoint system successfully demonstrated that a flexible, user-friendly platform for hosting CDS tools outside of a specific EHR is feasible. The forthcoming results of our outcomes analyses will demonstrate the adoption rate of EvidencePoint tools as well as the impact of behavioral economics "nudges" on the adoption rate. Due to the EHR-agnostic nature of EvidencePoint, the development process for additional forms of CDS will be simpler than traditional and cumbersome IT integration approaches and will benefit from the capabilities provided by the core system of EvidencePoint.

Immunologic Heterogeneity in 2 Cartilage-Hair Hypoplasia Patients With a Distinct Clinical Course

BACKGROUND AND OBJECTIVE

Cartilage-hair hypoplasia (CHH) syndrome is a rare autosomal recessive syndrome associated with skeletal dysplasia, varying degrees of combined immunodeficiency (CID), short stature, hair hypoplasia, macrocytic anemia, increased risk of malignancies, and Hirschsprung disease. To provide clinical and immunological insights obtained from 2 unrelated patients who displayed clinical characteristics of CHH.

METHODS

Two patients with suspected CHH syndrome due to skeletal dysplasia and immunodeficiency underwent an immunological and genetic work-up using flow cytometry, next-generation sequencing (NGS) of the immune repertoire, and Sanger sequencing to identify the underlying defects.

RESULTS

Patient 1 presented with low birth weight and skeletal dysplasia. Newborn screening was suggestive of T-cell immunodeficiency, as T-cell receptor excision circle levels were undetectable. Both the T-cell receptor (TCR) Vß and TCR-g (TRG) repertoires were restricted, with evidence of clonal expansion. Genetic analysis identified compound heterozygous RMRP variants inherited from both parents. Patient 2 presented with recurrent lung and gastrointestinal infections, skeletal dysplasia, failure to thrive, and hepatomegaly. The polyclonal pattern of the TCRß repertoire was normal, with only slight overexpression of TCR-ßV20 and restricted expression of Vßs. TRG expressed a normal diverse repertoire, similar to that of the healthy control sample. Genetic analysis identified biallelic novel regulatory variants in RMRP. Both parents are carriers of this mutation.

CONCLUSION

Our findings demonstrate how the immunological work-up, supported by genetic findings, can dramatically change treatment and future outcome in patients with the same clinical syndrome.

Perspectives on the Use of Outpatient Parenteral Antibiotic Therapy for People who Inject Drugs: Results From an Online Survey of Infectious Diseases Clinicians

Injection-related infections require prolonged antibiotic therapy. Outpatient parenteral antimicrobial therapy (OPAT) has been shown to be feasible for people who inject drugs (PWID) in some settings. We report a national survey on practice patterns and attitudes of infectious diseases clinicians in the United States regarding use of OPAT for PWID.

Telemedicine for unhealthy alcohol use in adults living with HIV in Alabama using common elements treatment approach: A hybrid clinical efficacy-implementation trial protocol

Background

Unhealthy alcohol use is an unaddressed barrier to achieving and maintaining control of the human immunodeficiency virus (HIV) epidemic. Integrated screening, treatment of common behavioral and mental health comorbidities, and telemedicine can improve alcohol treatment and HIV clinical and quality of life outcomes for rural and underserved populations.

Objective

In a randomized controlled clinical trial, we will evaluate the effectiveness and implementation of telephone-delivered Common Elements Treatment Approach (T-CETA), a transdiagnostic cognitive behavioral therapy protocol, on unhealthy alcohol use, HIV, other substance use and mental health outcomes among predominantly rural adults with HIV receiving care at community clinics in Alabama.

Methods

Adults with HIV receiving care at four selected community clinics in Alabama will receive a telephone-delivered alcohol brief intervention (BI), and then be assigned at random (stratified by clinic and sex) to no further intervention or T-CETA. Participants will be recruited after screening positively for unhealthy alcohol use or when referred by a provider. The target sample size is 308. The primary outcome will be change in the Alcohol Use Disorder Identification Test (AUDIT) at six- and 12-months post-enrollment. Additional outcomes include HIV (retention in care and viral suppression), patient-reported mental health (anxiety, depression, posttraumatic stress), and quality of life. A range of implementation measures be evaluated including T-CETA provider and client acceptability, feasibility, cost and cost-effectiveness.

Conclusions

This trial will inform alcohol treatment within HIV care programs, including the need to consider comorbidities, and the potential impact of alcohol interventions on HIV and quality of life outcomes.

HIV and Addiction Services for People Who Inject Drugs: Healthcare Provider Perceptions on Integrated Care in the U.S. South

This qualitative study evaluates physician training and experience with treatment and prevention services for people who inject drugs (PWID) including medications for opioid use disorder (MOUD) and HIV pre-exposure prophylaxis (PrEP). The Behavioral Model of Healthcare Utilization for Vulnerable Populations was applied as a framework for data analysis and interpretation. Two focus groups were conducted, one with early career physicians (n = 6) and one with mid- to late career physicians (n = 3). Focus group transcripts were coded and analyzed using thematic analysis to identify factors affecting implementation of treatment and prevention services for PWID. Respondents identified that increasing the availability of providers prescribing MOUD was a critical enabling factor for PWID seeking and receiving care. Integrated, interdisciplinary services were identified as an additional resource although these remain fragmented in the current healthcare system. Barriers to care included provider awareness, stigma associated with substance use, and access limitations. Providers identified the interwoven risk factors associated with injection drug use that must be addressed, including the risk of HIV acquisition, notably more at the forefront in the minds of early career physicians. Additional research is needed addressing the medical education curriculum, health system, and healthcare policy to address the addiction and HIV crises in the U.S. South.

Methamphetamines and Serious Injection-Related Infections: Opioid Use Care Continuum and Opportunities to End Alabama's Drug Crisis

Background

Increasingly, injection opioid use and opioid use disorder (OUD) are complicated by methamphetamine use, but the impact of stimulant use on the care of people who inject drugs (PWID) with serious injection-related infections (SIRIs) is unknown. The objective of this study was to explore hospital outcomes and postdischarge trends for a cohort of hospitalized PWID to identify opportunities for intervention.

Methods

We queried the electronic medical record for patients hospitalized at the University of Alabama at Birmingham with injection drug use-related infections between 1/11/2016 and 4/24/2021. Patients were categorized as having OUD only (OUD), OUD plus methamphetamine use (OUD/meth), or injection of other substance(s) (other). We utilized statistical analyses to assess group differences across hospital outcomes and postdischarge trends. We determined the OUD continuum of care for those with OUD, with and without methamphetamine use.

Results

A total of 370 patients met inclusion criteria-many with readmissions (98%) and high mortality (8%). The majority were White, male, and uninsured, with a median age of 38. One in 4 resided outside of a metropolitan area. There were significant differences according to substance use in terms of sociodemographics and hospital outcomes: patients with OUD/meth were more likely to leave via patient-directed discharge, but those with OUD only had the greatest mortality. Comorbid methamphetamine use did not significantly impact the OUD care continuum.

Conclusions

The current drug crisis in AL will require targeted interventions to engage a young, uninsured population with SIRI in evidence-based addiction and infection services.

744. Infectious Diseases Providers Perspectives Around the Use of Outpatient Parenteral Antibiotic Therapy (OPAT) for Persons Who Inject Drugs (PWID), US, 2022

Background

Injection drug use-related infections are life threatening and may require prolonged courses of antibiotic therapy. There is no consensus on best practices for serious infections when patients are stable for discharge. Outpatient parenteral antimicrobial therapy (OPAT) has been shown to be feasible for people who inject drugs (PWID) especially when paired with medication for opioid use disorder. We set out to determine the current practice patterns and attitudes of infectious diseases (ID) clinicians in the United States regarding the use of OPAT for PWID.

Methods

We surveyed ID clinicians between January 2022 and March 2022. Topics focused on PWID including OPAT access, barriers to inclusion in OPAT, and factors clinicians considered for OPAT success. Responses from those who perceived PWID were eligible for OPAT (PWID-E) were compared to those who believed PWID were ineligible (PWID-I) using the Pearson chi-squared test.

Results

Of 239 clinician respondents, 80% were MD, 6% DO, 5% NP, 2% PA, and 7% Pharmacists. 187 (78.2%) work at an academic practice and 179 (75%) work in an urban setting. 182 (76%) respondents have access to inpatient addiction medicine services and 206 (86%) reported availability of outpatient addiction treatment, but only 86 (36%) described patient access to outpatient services as “good” or “excellent.”

Respondents were categorized as PWID-E (n=171, 72%) and PWID-I (n=68, 28%). Of the PWID-E group, only 48 (28%) have an institutional policy for determining eligibility. There was no significant difference in practice setting or access to addiction services between PWID-E and PWID-I. Access to inpatient and outpatient social work/case management was significantly higher for PWID-E. (Table 1).

Clinicians reporting PWID-I were more likely to cite risk of tampering with PICC (76.5% vs 62.6%, p = 0.04) and medical-legal risk (47.1% vs 19.3%, p < 0.001) as barriers to OPAT. (Table 2).

Conclusion

A high proportion of respondents to this national survey offer OPAT for PWID, but only a minority have an institutional policy for eligibility. Guidelines that outline a framework for discharge decision making, education regarding medical and legal risk, and development of best practices may help to standardize care across settings.

Disclosures

Ellen Eaton, MD, MPH, Gilead HIV Research Scholar: Grant/Research Support|Gilead HIV research scholar: Grant/Research Support Monica K. Sikka, MD, F2G: Site research investigator.

1410. Methamphetamines and Serious Injection Related Infections: Epidemiology and Outcomes of Alabama’s Drug Crisis

Background

The U.S. is facing a steep increase in infectious consequences of intravenous drug use due to the ongoing opioid crisis, surging methamphetamine use, and health care disruptions caused by COVID-19. We hypothesize that the sociodemographic and clinical outcomes of persons who inject drugs (PWID) differ based on their drug of choice (opioids, methamphetamines). Further, we hypothesize that the OUD (opioid use disorder) continuum, including linkage and retention in OUD treatment, will vary depending on co-occurring methamphetamine use. By elucidating differences in these groups, we aim to identify opportunities for interventions along the care continuum.

Methods

This is a retrospective study of hospitalized PWID receiving care at the University of Alabama at Birmingham Hospital for a serious injection related infection (SIRI) between 1/11/2016 and 4/24/2021. We queried the EMR for clinical data and health outcomes. We extracted data on substance use disorder(s), treatments, and linkage to care through review of primary and addiction medicine consultation notes. Using statistical measures of association, we compared demographic factors and clinical outcomes among groups; delineating between those with and without methamphetamine use, and without OUD. When appropriate, additional comparisons were made to detect statistical differences between factors and those with and without methamphetamine use.

Results

Of 370 PWID, 286 had OUD, 94 had OUD and methamphetamine use, and 84 had another substance use disorder. There were significant differences according to drug use disorder with patients with OUD and meth use being mostly White (99%), 42% female, and younger relative to those who use opioids only. Patient directed discharge was most common among those with OUD plus meth use, but death was highest for those with OUD only. The OUD care continuum was similar and alarming for both groups with many gaps in care. Figure 1.

Expanding access to substance use services and mental health care for people with HIV in Alabama, a technology readiness assessment using a mixed methods approach

BACKGROUND

Alabama is one of seven priority states for the National Ending the HIV Epidemic Initiative due to a large rural burden of disease. Mental health (MH) and substance use disorders (SUD) represent obstacles to HIV care in rural areas lacking Medicaid expansion and infrastructure. Evidence-informed technologies, such as telehealth, may enhance SUD and MH services but remain understudied in rural regions.

METHODS

We conducted a readiness assessment using a mixed methods approach to explore opportunities for enhanced SUD and MH screening using electronic patient reported outcomes (ePROs) and telehealth at five Ryan White HIV/AIDS Program-funded clinics in AL. Clinic providers and staff from each site (N = 16) completed the Organizational Readiness to Implement Change (ORIC) assessment and interviews regarding existing services and readiness to change. People with HIV from each site (PLH, N = 18) completed surveys on the acceptability and accessibility of technology for healthcare.

RESULTS

Surveys and interviews revealed that all clinics screen for depression annually by use of the Patient Health Questionnaire-9 (PHQ9). SUD screening is less frequent and unstandardized. Telehealth is available at all sites, with three of the five sites beginning services due to the COVID-19 pandemic; however, telehealth for MH and SUD services is not standardized across sites. Results demonstrate an overall readiness to adopt standardized screenings and expand telehealth services beyond HIV services at clinics. There were several concerns including Wi-Fi access, staff capacity, and patients' technological literacy. A sample of 18 people with HIV (PWH), ages 18 to 65 years, participated in surveys; all demonstrated adequate technology literacy. A majority had accessed telehealth and were not concerned about it being too complicated or limiting communication. There were some concerns around lack of in-person interaction and lack of a physical exam and high-quality care with telehealth.

CONCLUSION

This study of PWH and the clinics that serve them reveals opportunities to expand SUD and MH services in rural regions using technology. Areas for improvement include implementing routine SUD screening, expanding telehealth while maintaining opportunities for in-person interaction, and using standardized ePROs that are completed by patients, in order to minimize stigma and bias.

[Factors associated with intrahospital mortality in older patients with COVID-19 in Belgium : The COVID-AgeBru study]

OBJECTIVE

We aimed at assessing the association between demographical and clinical data and the intrahospital mortality in older patients with COVID-19 in Belgium.

METHODS

Descriptive, retrospective study of consecutive patients admitted to Brugmann university hospital, Brussels (Belgium) due to COVID-19 (Mars-September-2020).

INCLUSION CRITERIA

Patients aged ≥ 70 years admitted to acute care with a positive PCR-RT test, or a highly indicative computed tomography scan.

EXCLUSION CRITERIA

Patients transferred to another institution during hospitalization.

OUTCOME MEASURE

All-cause intrahospital mortality. Demographic, clinical data, presence of comordibidties and comprehensive geriatric assessment were collected. Adjusted and unadjusted logistic regression were performed.

RESULTS

From the 226 eligible patients, 160 (82.7 ± 6.5-year-old; 57.5 % females) met inclusion criteria, from which 67 (42 %) died during hospital stay. The adjusted logistic regression showed an association between intrahospital mortality and increasing age [OR = 1.09 per every year increase (95 % CI 1.02-1.16); p <0.001], type 2 diabetes [OR = 2.75 ( 1.17-6.46); p = 0.021], and acute respiratory distress syndrome (ARDS) [OR = 8.67 ( 3.48-21.61); p < 0.01].

CONCLUSIONS

A higher positive association between intrahospital mortality and increasing age, type 2 diabetes, and ARDS was found. The prognosis value of the comprehensive geriatric assessment in older people with COVID-19 in Belgium requires further studies.

T1 Mapping for Microstructural Assessment of the Cervical Spinal Cord in the Evaluation of Patients with Degenerative Cervical Myelopathy

BACKGROUND AND PURPOSE

Although current radiologic evaluation of degenerative cervical myelopathy by conventional MR imaging accurately demonstrates spondylosis or degenerative disc disease causing spinal cord dysfunction, conventional MR imaging still fails to provide satisfactory anatomic and clinical correlations. In this context, we assessed the potential value of quantitative cervical spinal cord T1 mapping regarding the evaluation of patients with degenerative cervical myelopathy.

MATERIALS AND METHODS

Twenty patients diagnosed with mild and moderate-to-severe degenerative cervical myelopathy and 10 healthy subjects were enrolled in a multiparametric MR imaging protocol. Cervical spinal cord T1 mapping was performed with the MP2RAGE sequence procedure. Retrieved data were processed and analyzed regarding the global spinal cord and white and anterior gray matter on the basis of the clinical severity and the spinal canal stenosis grading.

RESULTS

Noncompressed levels in healthy controls demonstrated significantly lower T1 values than noncompressed, mild, moderate, and severe stenotic levels in patients. Concerning the entire spinal cord T1 mapping, patients with moderate-to-severe degenerative cervical myelopathy had higher T1 values compared with healthy controls. Regarding the specific levels, patients with moderate-to-severe degenerative cervical myelopathy demonstrated a T1 value increase at C1, C7, and the level of maximal compression compared with healthy controls. Patients with mild degenerative cervical myelopathy had lower T1 values than those with moderate-to-severe degenerative cervical myelopathy at the level of maximal compression. Analyses of white and anterior gray matter confirmed similar results. Strong negative correlations between individual modified Japanese Orthopaedic Association scores and T1 values were also observed.

CONCLUSIONS

In this preliminary study, 3D-MP2RAGE T1 mapping demonstrated increased T1 values in the pathology tissue samples, with diffuse medullary alterations in all patients with degenerative cervical myelopathy, especially relevant at C1 (nonstenotic level) and at the maximal compression level. Encouraging correlations observed with the modified Japanese Orthopaedic Association score make this novel approach a potential quantitative biomarker related to clinical severity in degenerative cervical myelopathy. Nevertheless, patients with mild degenerative cervical myelopathy demonstrated nonsignificant results compared with healthy controls and should now be studied in multicenter studies with larger patient populations.

In-Hospital 30-Day Survival Among Young Adults With Coronavirus Disease 2019: A Cohort Study

BACKGROUND

Our objective was to characterize young adult patients hospitalized with coronavirus disease 2019 (COVID-19) and identify predictors of survival at 30 days.

METHODS

This retrospective cohort study took place at 12 acute care hospitals in the New York City area. Patients aged 18-39 hospitalized with confirmed COVID-19 between March 1 and April 27, 2020 were included in the study. Demographic, clinical, and outcome data were extracted from electronic health record reports.

RESULTS

A total of 1013 patients were included in the study (median age, 33 years; interquartile range [IQR], 28-36; 52% female). At the study end point, 940 (92.8%) patients were discharged alive, 18 (1.8%) remained hospitalized, 5 (0.5%) were transferred to another acute care facility, and 50 (4.9%) died. The most common comorbidities in hospitalized young adult patients were obesity (51.2%), diabetes mellitus (14.8%), and hypertension (13%). Multivariable analysis revealed that obesity (adjusted hazard ratio [aHR], 2.71; 95% confidence interval [CI], 1.28-5.73; P = .002) and Charlson comorbidity index score (aHR, 1.20; 95% CI, 1.07-1.35; P = .002) were independent predictors of in-hospital 30-day mortality.

CONCLUSIONS

Obesity was identified as the strongest negative predictor of 30-day in-hospital survival in young adults with COVID-19.

Characterization of the public transit air microbiome and resistome reveals geographical specificity

BACKGROUND

The public transit is a built environment with high occupant density across the globe, and identifying factors shaping public transit air microbiomes will help design strategies to minimize the transmission of pathogens. However, the majority of microbiome works dedicated to the public transit air are limited to amplicon sequencing, and our knowledge regarding the functional potentials and the repertoire of resistance genes (i.e. resistome) is limited. Furthermore, current air microbiome investigations on public transit systems are focused on single cities, and a multi-city assessment of the public transit air microbiome will allow a greater understanding of whether and how broad environmental, building, and anthropogenic factors shape the public transit air microbiome in an international scale. Therefore, in this study, the public transit air microbiomes and resistomes of six cities across three continents (Denver, Hong Kong, London, New York City, Oslo, Stockholm) were characterized.

RESULTS

City was the sole factor associated with public transit air microbiome differences, with diverse taxa identified as drivers for geography-associated functional potentials, concomitant with geographical differences in species- and strain-level inferred growth profiles. Related bacterial strains differed among cities in genes encoding resistance, transposase, and other functions. Sourcetracking estimated that human skin, soil, and wastewater were major presumptive resistome sources of public transit air, and adjacent public transit surfaces may also be considered presumptive sources. Large proportions of detected resistance genes were co-located with mobile genetic elements including plasmids. Biosynthetic gene clusters and city-unique coding sequences were found in the metagenome-assembled genomes.

CONCLUSIONS

Overall, geographical specificity transcends multiple aspects of the public transit air microbiome, and future efforts on a global scale are warranted to increase our understanding of factors shaping the microbiome of this unique built environment.

95 Lack of Evidence for Reduced Efficacy of Medical Therapy for Heart Failure in Older Adults

Introduction

There are almost a million people with heart failure (HF) in the UK; the incidence increases sharply with age. Older adults receive less evidence-based therapy with few trials specifically examining therapeutic efficacy in older age groups representative of a contemporary UK HF population. Concern that efficacy is less in older adults may underlie under-prescription. With important recent advances in HF therapy, we reviewed the contemporary evidence base for any signal of different efficacy in older adults.

Methods

We reviewed recent RCTs of medical therapy for heart failure alongside meta-analyses updated with recent therapies including Angiotensin-Neprilysin inhibitors and SGLT2 inhibitors. For those trials in which effect size was presented for age subgroups we compared the effect size.

Results

Of 68 randomised controlled trials, 10 presented effect sizes for different age groups. The median average cut-off between younger and older age groups was 66 years (IQR 65 to 72.5 years) and the highest cut-off used was 75 years. The median hazard ratio was 0.77 (IQR 0.67 to 0.80) for the younger age group and 0.76 (IQR 0.73 to 0.88) for the older age group. In 8 of the 10 trials, the effect size in the oldest age group was statistically significant on its own including Sacubitril-Valsartan and Dapagliflozin.

Conclusion

When considering the medical therapeutic armamentarium for heart failure as a totality, there is no evidence it is any less effective in older adults than younger adults. The recent Zannad et al cross-trial analysis supported this showing significant additional life years in the patients over 80 years on HF therapy. Whilst there may be practical and frailty-related reasons for not prescribing life-prolonging therapy, the proportional survival benefits of these medications is similar in older adults. This should be utilised where practically possible and discussed with patients when making an informed choice.

Trauma Exposure and Problem Drinking in Late Adolescence: A Latent Profile Analysis

Exposure to early traumatic events has been implicated in problem drinking during late adolescence, and this association may be stronger among youth with emotion regulation deficits. The purpose of this study was to identify subgroups of late adolescents based on trauma type, including loss, posttraumatic stress disorder (PTSD) symptoms; and emotion regulation deficits that confer the risk for problematic drinking behaviors. A sample of 946 participants (M age = 18.84 years, SD = 1.06) was analyzed with mixed-indicator latent profile analysis to identify subgroups and explore whether these subgroups displayed significant differences regarding elevated drinking frequency, alcohol quantity, and problematic alcohol use. A four-profile model yielded the best fit to the data, and four groups were identified and labeled "high functioning" (29.4%), "loss regulated" (32.3%), "loss dysregulated" (28.1%), and "multiple trauma dysregulated" (10.1%). Individuals in the high functioning group reported the lowest rates on all three measures of alcohol misuse (14.6-24.9%), whereas those in the multiple trauma dysregulated group reported the highest rates on all three measures (31.6-71.5%). Individuals in the multiple trauma dysregulated group (M = 0.25) differed significantly from those in the other three groups (Ms = 0.42-0.72) on the measure of problematic alcohol use but scored similarly to those in the loss dysregulated group on measures of drinking frequency (M = 0.32 and 0.24, respectively) and quantity (M = 0.43 and 0.39, respectively). These findings have implications for prevention programs targeted for alcohol use disorders among older adolescents.

Metabolic and Renal Effects of Mammalian Target of Rapamycin Inhibitors Treatment After Liver Transplantation: Real-Life Single-Center Experience

BACKGROUND

Mammalian target of rapamycin (mTOR) inhibitors following liver transplantation (LT) are used to minimize calcineurin inhibitor (CNI)-related nephrotoxicity. Data about metabolic effects of mTOR inhibitors are still limited.

AIM

This study aims to determine the renal and metabolic effects of different mTOR inhibitor-based protocols in real-life LT patients.

METHODS

This is a retrospective cohort study of patients treated with mTOR inhibitors after LT. Demographics, treatment protocols, glomerular filtration rate (GFR), and metabolic parameters were collected over a period of 4 years. Initiation of blood pressure (BP), diabetes mellitus, and lipid medications was also noted.

RESULTS

Fifty-two LT recipients received mTOR inhibitors. GFR improved significantly (by 1.96 mL/min/year), with greater improvement in patients with baseline renal dysfunction (+13.3 mL/min vs +4.5 mL/min at 3 years). Conversion to an mTOR inhibitor during the first post-transplant year resulted in a more durable improvement in GFR (for 4 years vs only 1 year for later conversion).No significant weight gain or new-onset diabetes mellitus was observed. However, there was some increase in total cholesterol (+7 mg/dL) and blood pressure (+2 mm Hg during the third year and +8 mm Hg in the fourth years), followed by initiation of lipid-lowering and BP medications in 25% and 13% of patients, respectively.

CONCLUSIONS

Treatment with an mTOR inhibitor following LT resulted in improved kidney functions without significant negative metabolic effects such as weight gain or new-onset diabetes mellitus. This makes mTOR inhibitors a valuable immunosuppressive option in the face of the growing incidence of nonalcoholic steatohepatitis as a leading cause for LT.

Clinical characteristics and functions of non-suicide self-injury in youth

Purpose

Little is known about the clinical characteristics and motivations for engaging in non-suicide self-injury (NSSI) behaviors in adolescence. The aim of this study was to examine the prevalence, characteristics and functions of NSSI among adolescents in community settings, and to explore risk factors related to this behavior.

Subjects and methods

Two hundred and seventy-five adolescents aged 12 to 17 were recruited randomly from different High Schools in Israel. They completed self-report questionnaires assessing NSSI (Ottawa Self-Injury Inventory), depression (Children's Depression Inventory – CDI) and impulsivity (Barratt Impulsiveness Scale – BIS-II).

Results

In the past year, 20.7% of the participants reported engaging NSSI at least once. Among them, 42.1% declared they are still engaging in NSSI at the present. Motives for NSSI were internal emotion regulation reasons, external emotion regulation reasons for social influences. In addition, the NSSI group reported significantly higher levels of depressive, impulsivity and suicidal ideations. Depressive symptoms were found as significant predictors of NSSI in the future.

Discussion and conclusions

High rates of NSSI among community adolescents were found. Depression, impulsivity and suicidal ideation were found significantly related to NSSI. Mental health professionals in schools and in primary care should routinely assess NSSI among adolescents.

P4775Efficacy and safety of vernakalant for cardioversion of recent-onset atrial fibrillation in real-world clinical practice: the SPECTRUM post-approval safety study

Background

Vernakalant is an antiarrhythmic agent designed for pharmacological conversion of recent onset of atrial fibrillation (AF) with combined action on cardiac potassium and sodium currents mainly concentrated in the atria.

Purpose

SPECTRUM was a post-authorisation safety study of vernakalant, conducted to collect information about real-life conditions of use and appropriate dosing, and to quantify possible medically significant risks associated with the use of vernakalant in real-world clinical practice.

Methods

This prospective and retrospective registry was conducted from Sep 2011 to Apr 2018 in 53 hospitals in EU countries including Austria, Denmark, Finland, Germany, Spain and Sweden. A total of 1,778 patients with 2,009 episodes of recent-onset AF received vernakalant and were followed up for 24 hours after the last infusion or until hospital discharge/end of medical encounter to obtain information on medically significant health outcomes of interest (HOIs, defined as significant hypotension, significant ventricular arrhythmia, significant atrial flutter, significant bradycardia), and serious adverse events (SAEs).

Results

In more than 99% of treatments, vernakalant was used in accordance to the labelled indication for conversion of AF for non-surgery (94.7%) or post-cardiac surgery patients (5.2%). Vernakalant was administered in the emergency department in 64.2% of cases, with a median stay of 7.5 hours and successfully converted 70.2% (95% CI: 68.1–72.2) of patients in the effectiveness analysis population with a median time to conversion of 11 minutes (95% CI: 8.0–27.0). A total of 19 HOIs were reported in 17 patients (0.8%, 95% CI: 0.5– .4%) with individual HOIs ranging from <0.1% to 0.7% suggesting these HOIs are uncommon. Significant bradycardia was the most common HOI observed in 15 patients (0.8%, 95% CI: 0.4–1.2%), with all events occurring within the first two hours (0.8%, 95% CI: 0.4–1.2%). The incidence of significant hypotension was 0.1% (2/2,009), significant atrial flutter (with 1:1 conduction) was 0.1% (2/2,009), and significant ventricular arrhythmia (sustained ventricular tachycardia) was <0.1% (1/2,009). A total of 28 SAEs, including all HOIs, were observed (1.3%, 95% CI: 0.8–1.9%); all patients fully recovered, except one who recovered with sequelae after an SAE of pericardial effusion definitely not related to vernakalant. There were no cases of torsades de pointes, ventricular fibrillation, or deaths reported in the SPECTRUM study.

Conclusion(s)

SPECTRUM is, to our knowledge, the largest drug registry conducted on the cardioversion of recent onset AF. The cumulative data from 2,009 vernakalant treatment episodes demonstrate an incidence of HOIs and SAEs similar or lower to what has been reported in earlier vernakalant IV clinical trials. The observed conversion rate was higher than reported in pivotal trials supporting vernakalant's efficacy and allowing early discharge.

Acknowledgement/Funding

Study funded by Correvio International Sarl, Geneva, Switzerland