Increasing Incidence of Streptococcus anginosus Group Intracranial Infections Associated With Sinusitis, Otitis Media, and Mastoiditis in Children

BACKGROUND

The Streptococcus anginosus group (SAG) pathogens have the potential to cause head and neck space infections, including intracranial abscesses. Several centers noted an increase in intracranial abscesses in children during the SARS-CoV-2 pandemic, prompting a Centers for Disease Control and Prevention health alert in May 2022. We examined the epidemiology of pediatric intracranial abscesses at a tertiary care center with a focus on SAG pre- and post-pandemic.

METHODS

Cases of intracranial abscesses of any microbiologic etiology admitted from January 2011 to December 2022 were identified using International Classification of Diseases 10 codes. Subjects were cross-referenced with culture results from the microbiology laboratory at Texas Children's Hospital. Cases included were those associated with either otitis media, mastoiditis or sinusitis and medical records were reviewed.

RESULTS

A total of 157 cases were identified and 59.9% (n = 94) were caused by SAG. The incidence of all sinogenic/otogenic intracranial infections (P = 0.002), and SAG-specific infections (P = 0.004), increased from 2011 to 2022. SAG infection was more often associated with multiple surgeries, and these subjects were more likely to require craniotomy or craniectomy. Among sinogenic abscesses, S. intermedius was the most common pathogen, while among otogenic cases, S. pyogenes predominated. From March 2020 to Dec 2022, 9/49 cases tested positive for SARS-CoV-2 (18.4%); characteristics of infection were not significantly different among cases with and without SARS-CoV-2.

CONCLUSIONS

Over the last decade, intracranial complications of sinusitis/otitis have been increasing, specifically those caused by SAG; this trend, however, predated the SARS-CoV-2 pandemic. SAG was associated with a greater need for surgical intervention, specifically neurosurgery. Further work is necessary to determine the cause for these rising infections.

Invasive Group A Streptococcus in Infants Less Than 1-year of Age From 2012 to 2022: A Single-Center Experience

The incidence of invasive Group A Streptococcus (iGAS) has varied throughout the COVID-19 pandemic. We reviewed iGAS infections in infants ≤1 year from 2012 to 2022. Twenty-five percent of cases occurred in the last quarter of 2022. Pneumonia (21.8%) was the most common presentation. Twenty-one patients (65.6%) were successfully transitioned to oral antibiotics.

Multiple staging investigations may not change management in patients with high-grade dysplasia or early esophageal adenocarcinoma

The clinical value of multiple staging investigations for high-grade dysplasia or early adenocarcinoma of the esophagus is unclear. A single-center prospective cohort of patients treated for early esophageal cancer between 2000 and 2019 was analyzed. This coincided with a transition period from esophagectomy to endoscopic mucosal resection (EMR) as the treatment of choice. Patients were staged with computed tomography (CT), endoscopic ultrasound (EUS) and 2-deoxy-2-[18F]fluoro-d-glucose (FDG) positron emission tomography(PET)/CT. The aim of this study was to assess their accuracy and impact on clinical management. 297 patients with high-grade dysplasia or early adenocarcinoma were included (endoscopic therapy/EMR n = 184; esophagectomy n = 113 [of which a 'combined' group had surgery preceded by endoscopic therapy n = 23]). Staging accuracy was low (accurate staging EMR: CT 40.1%, EUS 29.6%, FDG-PET/CT 11.0%; Esophagectomy: CT 43.3%, EUS 59.7%, FDG-PET/CT 29.6%; Combined: CT 28.6%, EUS46.2%, FDG-PET/CT 30.0%). Staging inaccuracies across all groups that could have changed management by missing T2 disease were CT 12%, EUS 12% and FDG-PET/CT 1.6%. The sensitivity of all techniques for detecting nodal disease was low (CT 12.5%, EUS 12.5%, FDG-PET/CT0.0%). Overall, FDG-PET/CT and EUS changed decision-making in only 3.2% of patients with an early cancer on CT and low-risk histology. The accuracy of staging with EUS, CT and FDG-PET/CT in patients with high-grade dysplasia or early adenocarcinoma of the esophagus is low. EUS and FDG-PET/CT added relevant staging information over standard CT in very few cases, and therefore, these investigations should be used selectively. Factors predicting the need for esophagectomy are predominantly obtained from EMR histology rather than staging investigations.

Butyrate induces development-dependent necrotizing enterocolitis-like intestinal epithelial injury via necroptosis

BACKGROUND

The accumulation of short-chain fatty acids (SCFAs) from bacterial fermentation may adversely affect the under-developed gut as observed in premature newborns at risk for necrotizing enterocolitis (NEC). This study explores the mechanism by which specific SCFA fermentation products may injure the premature newborn intestine mucosa leading to NEC-like intestinal cell injury.

METHODS

Intraluminal injections of sodium butyrate were administered to 14- and 28-day-old mice, whose small intestine and stool were harvested for analysis. Human intestinal epithelial stem cells (hIESCs) and differentiated enterocytes from preterm and term infants were treated with sodium butyrate at varying concentrations. Necrosulfonamide (NSA) and necrostatin-1 (Nec-1) were used to determine the protective effects of necroptosis inhibitors on butyrate-induced cell injury.

RESULTS

The more severe intestinal epithelial injury was observed in younger mice upon exposure to butyrate (p = 0.02). Enterocytes from preterm newborns demonstrated a significant increase in sensitivity to butyrate-induced cell injury compared to term newborn enterocytes (p = 0.068, hIESCs; p = 0.038, differentiated cells). NSA and Nec-1 significantly inhibited the cell death induced by butyrate.

CONCLUSIONS

Butyrate induces developmental stage-dependent intestinal injury that resembles NEC. A primary mechanism of cell injury in NEC is necroptosis. Necroptosis inhibition may represent a potential preventive or therapeutic strategy for NEC.

IMPACT

Butyrate induces developmental stage-dependent intestinal injury that resembles NEC. A primary mechanism of cell injury caused by butyrate in NEC is necroptosis. Necroptosis inhibitors proved effective at significantly ameliorating the enteral toxicity of butyrate and thereby suggest a novel mechanism and approach to the prevention and treatment of NEC in premature newborns.

Development and performance of a multiplex PCR assay for the detection of bacteria in sterile body fluids

Aim: To assess the performance characteristics of a lab-developed multiplex PCR assay for the detection of common bacterial pathogens associated with infections in pediatric patients from normally sterile sites, such as cerebrospinal fluid, synovial and pleural fluids. Materials & methods: A total of 272 specimens were tested by PCR and traditional culture methods to assess the presence of Neisseria meningitidis, Streptococcus pneumoniae, Streptococcus pyogenes, methicillin-sensitive and methicillin-resistant Staphylococcus aureus, and Kingella kingae. Results: Compared with culture, the overall positive and negative percentage agreement of the PCR were 95.9% and 74.1%, respectively. Conclusion: This sterile body fluid PCR affords a rapid and sensitive alternative for bacterial detection, allowing for more timely pathogen-directed antimicrobial therapy.

Histological evidence of superficial inflammation is associated with lower recurrence of equine sarcoids following surgical removal: A follow-up study of 106 tumours in 64 horses

Although the equine sarcoid is the most common skin neoplasm in domesticated horses, histopathological characteristics have not previously been evaluated for association with recurrence. The aim of this retrospective cohort study was to investigate clinical and histopathological features of excised equine sarcoids and to evaluate their association with recurrence at the original surgical site and at new sites. Clinical records and excisional biopsies from 106 equine sarcoids from 64 horses referred to Leahurst Equine Hospital, University of Liverpool, between March 2010 and February 2015 were retrieved. Biopsies were re-evaluated histologically. Clinical data were obtained from hospital records, and owner-reported follow-up data were obtained by telephone questionnaire. Associations between clinical and histopathological features of sarcoids and their recurrence at the surgical site were determined using uni- and multivariable mixed effects logistic regression. Recurrence of sarcoids at the surgical site occurred in 30 horses (46.9%). Sarcoids developed at a distant site in 21 horses (32.8%). In the final mixed effects logistic regression model, only superficial inflammation was associated with reduced odds of recurrence at the surgical site (adjusted odds ratio, 0.32; 95% confidence intervals, 0.10-0.96; P = 0.04). This suggests that the inflammatory process may play a role in protecting horses against the recurrence of sarcoids.

Prognostic stratification of HPV-associated oropharyngeal cancer based on CD103+ immune cell abundance in patients treated on TROG 12.01 and De-ESCALaTE randomized trials

BACKGROUND

High CD103+ intratumoral immune cell (ITIC) abundance is associated with better prognosis in unselected patients with human papilloma virus-associated oropharyngeal squamous cell carcinoma (HPV-associated OPSCC) treated with cisplatin and radiotherapy (CIS/RT). Substituting cetuximab (CETUX) for CIS with RT in HPV-associated OPSCC resulted in inferior efficacy. Our aim was to determine whether quantification of CD103 ITIC could be used to identify a population of HPV-associated OPSCC with superior prognosis.

PATIENTS AND METHODS

We pooled data from the TROG 12.01 and De-ESCALaTE randomized trials that compared CETUX/70GyRT with CIS/70GyRT in low-risk HPV-associated OPSCC: American Joint Committee on Cancer 7 stage III (excluding T1-2N1) or stage IV (excluding N2b-c if smoking history >10 pack-years and/or distant metastases), including all patients with available tumor samples. The primary endpoint was failure-free survival (FFS) in patients receiving CETUX/RT comparing CD103+ ITIC high (≥30%) versus low (<30%). High and low CD103 were compared using Cox regression adjusting for age, stage and trial.

RESULTS

Tumor samples were available in 159/182 patients on TROG 12.01 and 145/334 on De-ESCALaTE. CD103+ ITIC abundance was high in 27% of patients. The median follow-up was 3.2 years. The 3-year FFS in patients treated with CETUX/RT was 93% [95% confidence interval (CI) 79% to 98%] in high CD103 and 74% (95% CI 63% to 81%) in low CD103 [adjusted hazard ratio = 0.22 (95% CI 0.12-0.41), P < 0.001]. The 3-year overall survival in patients treated with CETUX/RT was 100% in high CD103 and 86% (95% CI 76% to 92%) in low CD103, P < 0.001. In patients treated with CIS/RT, there was no significant difference in FFS.

CONCLUSIONS

CD103+ ITIC expression separates CETUX/RT-treated low-risk HPV-associated OPSCC into excellent and poor prognosis subgroups. The high CD103 population is a rational target for de-intensification trials.

Colostrum management practices that improve the transfer of passive immunity in neonatal dairy calves: A scoping review

The objective of this scoping review was to describe the literature on the characteristics and management practices of colostrum feeding and their associations with the level of transfer of passive immunity (TPI) in dairy calves. Observational and experimental studies were searched in 5 electronic databases and 3 conference proceedings. Two reviewers independently screened primary studies, either analytic observational or experimental studies written in English. Studies on dairy or dual-purpose calves with passive immunity analyzed by blood sampling between 1 to 9 days of age were included. All studies had to compare at least one colostrum intervention or risk factor and their association with passive immunity. Of the 3,675 initially identified studies, 256 were included in this synthesis. One hundred and ninety-five were controlled trials, 57 were cohort studies, and 4 were cross-sectional studies. The effect of colostral quantity at first feeding was investigated in 30 controlled studies including studies that were comparable to each other. The effect of colostral quality was explored in 24 controlled studies with inconsistent criteria used to define the quality. The effect of the timing of first feeding of colostrum was investigated in 21 controlled studies, where the timing of feeding ranged widely from immediately after birth to 60 h of age. Only 4 controlled studies evaluated the relationship between bacterial load in the colostrum and TPI in dairy calves. Of the 256 total studies, 222 assessed blood IgG concentration while 107 measured blood total protein concentration. We identified a gap in knowledge on the association between passive immunity in dairy calves and the bacterial load in colostrum, or the timing of harvesting colostrum from the dam. A possible quantitative synthesis could be conducted among the studies that evaluated colostral quantity at the first feeding in relation to TPI in dairy calves.

The Effect of the ENJOY Seniors Exercise Park Physical Activity Program on Falls in Older People in the Community: A Prospective Pre-Post Study Design

BACKGROUND

The ENJOY project (Exercise interveNtion outdoor proJect in the cOmmunitY for older people) is a community-based research project actively promoting physical activity engagement through the delivery of an exercise program using outdoor multimodal exercise equipment. This study investigated the impact of the physical activity program on falls in older people.

METHOD

This study was a multi-site prospective study with a pre-post intervention design and 12-month follow up. Eighty older people with increased falls risk underwent a 12-week supervised outdoors exercise program followed by a 6-month maintenance phase. The proportion of fallers and falls incidence were compared between the preceding and the prospective years.

RESULTS

A sample of 54 (age 72.4±7.3, 79.6% women) was available for the 12 months analysis (due to COVID19 lockdowns, data of 19 participants were excluded and 4 dropped out). Number of fallers (from 51.8% to 31.4%, p=0.03) and falls incidence (from 42 to 29 falls, p<0.01) were significantly reduced at the 12-months follow up.

CONCLUSION

The ENJOY Seniors Exercise Park program integrates outdoor multimodal exercise stations including specific exercises designed to challenge dynamic balance during functional daily movements. The outcomes provide preliminary evidence for the potential positive impact of the ENJOY Seniors Exercise Park in reducing falls for older people.

Multiplex PCR Pathogen Detection in Acute Gastroenteritis Among Hospitalized US Children Compared With Healthy Controls During 2011-2016 in the Post-Rotavirus Vaccine Era

Background

Despite vaccine-induced decreases in US rotavirus (RV) disease, acute gastroenteritis (AGE) remains relatively common. We evaluated AGE pathogen distribution in hospitalized US children in the post–RV vaccine era.

Methods

From December 2011 to June 2016, the New Vaccine Surveillance Network (NVSN) conducted prospective, active, population-based surveillance in hospitalized children with AGE. We tested stools from 2 NVSN sites (Kansas City, Houston) with Luminex x-TAG Gastrointestinal Pathogen Panels (Luminex GPP) and analyzed selected signs and symptoms.

Results

For 660 pediatric AGE inpatients and 624 age-matched healthy controls (HCs), overall organism detection was 51.2% and 20.6%, respectively (P < .001). Among AGE subjects, GPP polymerase chain reaction detected >1 virus in 39% and >1 bacterium in 14% of specimens. Detection frequencies for AGE subjects vs HCs were norovirus (NoV) 18.5% vs 6.6%, RV 16.1% vs 9.8%, adenovirus 7.7% vs 1.4%, Shigella 4.8% vs 1.0%, Salmonella 3.1% vs 0.1%, and Clostridioides difficile in ≥2-year-olds 4.4% vs 2.4%. More co-detections occurred among AGE patients (37/660, 5.6%) than HCs (14/624, 2.2%; P = .0024). Per logistic regression analysis, ill contacts increased risk for NoV, RV, and Shigella (P < .001). More vomiting episodes occurred with NoV and RV, and more diarrheal episodes with Shigella and Salmonella. Modified Vesikari scores were highest for Shigella and lowest for C. difficile.

Conclusions

NoV detection was most frequent; however, RV remained important in hospitalized AGE in the post–RV vaccine era. Continued active surveillance is important to document ongoing vaccine effects, pathogen emergence, and baseline disease burden for new vaccines.

Improvement in Dysphagia Outcomes Following Clinical Target Volume Reduction in the De-ESCALaTE Study

AIMS

The De-ESCALaTE study showed an overall survival advantage for the administration of synchronous cisplatin chemotherapy with radiotherapy in low-risk oropharyngeal cancer when compared with synchronous cetuximab. During the trial, a radiotherapy quality assurance protocol amendment permitted centres to swap from the original radiotherapy contouring protocol (incorporating the whole oropharynx into the high-dose clinical target volume (CTV); anatomical protocol) to a protocol that incorporated the gross tumour volume with a 10 mm margin into the CTV (volumetric protocol). The purpose of this study was to examine both toxicity and tumour control related to this protocol amendment.

MATERIALS AND METHODS

Overall survival and recurrence at 2 years were used to compare tumour control in the two contouring cohorts. For toxicity, the cohorts were compared by both the number of severe (grades 3-5) and all grades acute and late toxicities. In addition, quality of life and swallowing were compared using EORTC-C30 and MD Anderson Dysphagia Inventory, respectively.

RESULTS

Of 327 patients included in this study, 185 were contoured according to the anatomical protocol and 142 by the volumetric protocol. The two cohorts were well balanced, with the exception of significantly more patients in the anatomical cohort undergoing prophylactic feeding tube insertion (P < 0.001). With a minimum of 2 years of follow-up there was no significant difference in overall survival or recurrence between the two contouring protocols. Similarly, there was no significant difference in the rate of reported severe or all grades acute or late toxicity and no sustained significant difference in quality of life. However, there was a significant difference in favour of volumetric contouring in several domains of the MD Anderson Dysphagia Inventory questionnaire at 1 year, which persisted to 2 years in the dysphagia functional (P = 0.002), dysphagia physical (P = 0.009) and dysphagia overall function (P = 0.008) domains.

CONCLUSION

In the context of the unplanned post-hoc analysis of a randomised trial, measurable improvement in long-term dysphagia has been shown following a reduction in the CTV. Further reductions in the CTV should be subject to similar scrutiny within the confines of a prospective study.

Characterizing the literature surrounding transportation of young dairy calves: A scoping review

Transportation is a stressful event for cattle, as it may involve various handling practices, commingling, deprivation of food and water, and fluctuating temperatures. Calves are particularly susceptible to these stressors because their physiological and immune systems are still developing. There has been no formal synthesis of the scientific literature evaluating the effect of transportation on young dairy calf health and performance; the aim of this scoping review is to describe and characterize this body of work. We targeted both descriptive and analytic studies examining transport of calves, including listing how the effect of transport has been evaluated. Eight databases were searched for relevant articles with eligible studies being primary research articles investigating transportation of calves of either sex who were younger than 60 d of age or weighed less than 100 kg. Two reviewers independently screened the title and abstracts of 6,859 articles with 361 potentially relevant articles screened at full text. Of these, 46 were relevant and had data extracted. Articles reporting study location were conducted in the United States (n = 5), Australia (n = 3), Japan (n = 3), and New Zealand (n = 3). Common transport-related variables evaluated included time in transit (n = 13), distance of transportation (n = 8), vehicle-related factors (n = 8), and age at time of transportation (n = 4). Outcome measures varied greatly, including blood parameters (n = 28), health assessments (n = 20), weight (n = 17), behavioral metrics (n = 14), mortality (n = 7), feed intake following transportation (n = 4), salivary cortisol concentrations (n = 3), morbidity (n = 3), and isolation of Salmonella Dublin in fecal samples (n = 2). Outcome parameters were measured during transport or ranged from immediately after to one year following transportation. As the transport-related risk factors and outcomes measured assessed varied widely between studies, future quantitative synthesis (e.g., meta-analysis) in this area may be limited. Several knowledge gaps were identified, including methods to prepare calves for transportation, such as improving nutrition, administering medication, or transporting calves at an older age or weight. Further research could also focus on consistent and clear reporting of key items related to study conduct and analysis, as well as the development of a core outcome set for calf transport studies.

OS08.5.A Proteomic analysis of meningioma

BACKGROUND

Meningioma is the most common primary intracranial tumor. Although ~80% are benign some WHO grade I are clinically aggressive. Chemotherapies are ineffective and biomarkers for clinical management are lacking. Approximately 60% sporadic meningiomas harbor mutations in the NF2 gene andutations in TRAF7, KLF4, AKT1, SMO and PIK3CA have been identified in the majority NF2-positive tumors esp lower grade. However, the molecular mechanisms behind meningioma tumourigenesis is still unclear. We aim to identify novel biomarkers and therapeutic targets of meningioma by characterizing the proteomic landscape.

MATERIAL AND METHODS

We analysed grade I, II and III frozen meningioma specimens and three different mutational groups: AKT1/TRAF7, KLF4/TRAF7 and NF2 -/- using LC-MS/MS to analyse global proteins, enriched phosphoproteins and phosphopeptides. Differential expression and functional annotation of proteins was completed using Perseus, IPA® and DAVID. For mutational subtypes quantitative phosphoproteomics was performed using TMT 10plex labeling approach followed by motif analysis using motif-X algorithm. We validated differential expression of proteins and phosphoproteins by Western blot and immunohistochemistry.

RESULTS

We quantified 3888 proteins and 3074 phosphoproteins across all meningioma grades. Bioinformatics analysis revealed commonly upregulated (phospho)proteins to be enriched in Gene Ontology terms associated with RNA metabolism. Validation confirmed significant overexpression of proteins such as EGFR, CKAP4, the nuclear proto-oncogene SET, the splicing factor SF2/ASF as well as total and activated phosphorylated form of the NIMA-related kinase, NEK9, involved in mitotic progression. Hexokinase 2 was overexpressed in higher grades. For the mutation subtypes we have quantified 4162 proteins across all mutational meningioma subgroups. Analysis showed distinct proteomic profiles of mutational subgroups. Comparative analysis showed 10 proteins were commonly significantly upregulated among all mutational subtypes vs. normal meninges. 257 proteins were commonly significantly downregulated and enriched with molecular functions including aldehyde dehydrogenase and oxido-reductase. Mutational subtype-specific analysis identified 162 proteins significantly upregulated in AKT1/TRAF7 vs. remaining sample groups to be enriched in the oxidative phosphorylation pathway. 14 and 7 proteins were commonly significantly upregulated in KLF4/TRAF7 and NF2 -/- mutant meningioma subtypes respectively. Several of these up-regulated proteins including ANNEXIN-3, CRABP2, CLIC3 and Endoglin were verified via WB. Lastly, analyses of 6600 phosphosites predicted regulatory kinases

CONCLUSION

We show extensive proteomic and phospophoproteomics analysis of meningioma and suggest new therapeutic and biomarker candidates.

A multicenter evaluation of viral bloodstream detections in children presenting to the Emergency Department with suspected systemic infection

Background

Fever is a common symptom in children presenting to the Emergency Department (ED). We aimed to describe the epidemiology of systemic viral infections and their predictive values for excluding serious bacterial infections (SBIs), including bacteremia, meningitis and urinary tract infections (UTIs) in children presenting to the ED with suspected systemic infections.

Methods

We enrolled children who presented to the ED with suspected systemic infections who had blood cultures obtained at seven healthcare facilities. Whole blood specimens were analyzed by an experimental multiplexed PCR test for 7 viruses. Demographic and laboratory results were abstracted.

Results

Of the 1114 subjects enrolled, 245 viruses were detected in 224 (20.1%) subjects. Bacteremia, meningitis and UTI frequency in viral bloodstream-positive patients was 1.3, 0 and 10.1% compared to 2.9, 1.3 and 9.7% in viral bloodstream-negative patients respectively. Although viral bloodstream detections had a high negative predictive value for bacteremia or meningitis (NPV = 98.7%), the frequency of UTIs among these subjects remained appreciable (9/89, 10.1%) (NPV = 89.9%). Screening urinalyses were positive for leukocyte esterase in 8/9 (88.9%) of these subjects, improving the ability to distinguish UTI.

Conclusions

Viral bloodstream detections were common in children presenting to the ED with suspected systemic infections. Although overall frequencies of SBIs among subjects with and without viral bloodstream detections did not differ significantly, combining whole blood viral testing with urinalysis provided high NPV for excluding SBI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02699-9.

A Surge in Pediatric Coronavirus Disease 2019 Cases: The Experience of Texas Children's Hospital From March to June 2020

BACKGROUND

An understanding of the clinical characteristics of children with coronavirus disease 2019 in diverse communities is needed to optimize the response of healthcare providers during this pandemic.

METHODS

We performed a retrospective review of all children presenting to the Texas Children's Hospital system with testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from March 10, 2020, through June 28, 2020. Demographics were recorded for all patients undergoing testing and clinical characteristics and outcomes were recorded for children with positive tests.

RESULTS

Of 16 554 unique patients ≤ 21 years of age who were tested for SARS-CoV-2, 1215 (7.3%) patients tested positive. Infants under 1 year of age and patients aged 18-21 years had the highest percent of positive tests at 9.9% (230/2329) and 10.7% (79/739), respectively. Hispanic children accounted for 66% (802/1215) of positive tests, though they only represented 42.1% (6972/16 554) of all children tested for SARS-CoV-2. Of the 1215 children with a positive test, 55.7% had fever, 40.9% had cough, 39.8% had congestion or rhinorrhea, 21.9% had gastrointestinal complaints, and 15.9% were asymptomatic. Only 97 (8%) patients were hospitalized (of which 68% were Hispanic). Most of the hospitalized patients had underlying medical conditions (62/97, 63.9%), including obesity. Thirty-one hospitalized patients (31/97, 32%) required respiratory support and 9 patients (9/97, 9.3%) received SARS-CoV-2 antiviral therapy. Two patients died.

CONCLUSIONS

A relatively high percentage of Hispanic children tested positive for SARS-CoV-2 and were hospitalized. Most of the children with detection of SARS-CoV-2 had uncomplicated illness courses; some children were critically ill; and 2 patients died.

203 Efficiency of SID lysine utilization and maximum SID lysine retention for gilts in early, mid and late gestation

Efficiency of amino acid (AA) use is presumed constant across gestation but may not reflect changes in metabolic demand during gestation nor consider changes in efficiency depending on level of AA intake. Two experiments were conducted to determine efficiency of SID Lys utilization in gilts during early (d 48-52), mid (d 75-79) and late gestation (d 103-107). Each experiment provided 4 isocaloric (3,335 kcal ME/kg) and isoproteic (11.75 % CP) diets containing 4 SID Lys levels (Table 1). Diets were randomly assigned to 45 gilts (PIC 1050, 158.0 ± 8.0 kg at d 39.4 ± 1 of gestation) in Exp. 1 and 27 gilts (PIC 1050, 169.0 ± 7.5 kg at d 41 ± 1 of gestation) in Exp. 2. Dietary indispensable AA were set to meet or exceed 100% of AA:Lys ratios in both experiments. The SID Lys retention was estimated from whole body nitrogen (N) retention balance studies in each period (7 d diet adaptation, 5 d total urine collection and grab fecal sampling) according to the NRC (2012) equations. The relationship between SID Lys intake and SID Lys retention was determined by nonlinear regression models using the CurveExpert Professional software. According to the Hoerl regression model: E(y)=exp(β 0+β 1X)[Xβ2] best-fitting line, maximum efficiency of SID Lys utilization (i.e. g SID Lys retention/g SID Lys intake) was 65%, 57%, and 53% in early, mid and late gestation and occurred at 6.6, 8 and 12 g of SID Lys intake/d, respectively. Maximum SID Lys retention occurred at 8.1 and 9.8 g of SID Lys intake/d for early and mid-gestation. The SID Lys retention did not reach a maximum value in late gestation. These results suggest that efficiency of SID Lys utilization is not constant across gestation and that maximal efficiency occurs at intake below current recommendations.

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Mycoplasma Genitalium And Streptococcus Agalactiae Colonization In Pregnant Women: An Emerging Relationship

Introduction/Objective

Mycoplasma genitalium has been identified as an emerging sexually transmitted infection (STI) causing cervicitis, pelvic inflammatory disease and other gynecologic pathology. The prevalence of M. genitalium in pregnant women has not been determined, nor has frequency of co-infection with Streptococcus agalactiae (GBS). Neonatal sepsis caused by GBS is associated with black race and young maternal age with approximately 10%-30% of pregnant women colonized. The aim of this retrospective study was to investigate the possible association between M. genitalium infection and colonization with GBS in a large cohort of pregnant women from a tertiary care center in Houston, Texas.

Methods

Remnant endocervical samples collected from pregnant women attending clinics at the Baylor College of Medicine between September 2019 and December 2019 were screened for M. genitalium by transcription mediated amplification (Hologic, Inc. Marlborough, MA). Demographic, STI co-infection [Human papillomavirus (types 16,18), Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, and Herpes simplex virus], and GBS status data were recorded. Fisher’s exact test was performed for statistical analysis.

Results

719 total samples were collected and tested for M. genitalium. Of these, 41 (5.7%) were positive. The mean age of infected women was younger than noninfected women (24.9 vs. 28.1 years respectively p = 0.0004). More black women (34.2%) were infected with M. genitalium compared to white (14.6%) or other (51.2%) (p = 0.0003).

Rates of GBS colonization was significantly higher among women infected with M. genitalium compared to women who tested negative (58.3% vs. 16.1% respectively p = 0.002) and increased compared to national reported rates of GBS colonization. M. genitalium also showed a significant association with T. vaginalis (p=0.03), but no other STI co- infections studied.

Conclusion

Our data demonstrates that infection with M. genitalium may be associated with persistent GBS colonization. Further prospective studies are needed to further elucidate this relationship.

Design of 3D-Printed Nasopharyngeal Swabs for Children is Enabled by Radiologic Imaging

3D-printed nasopharyngeal swabs for COVID-19 molecular diagnostic testing address the national shortage of swabs. Swab designs for adult use were placed in the public domain in March 2020. Swabs for pediatric use, however, need to be smaller and more flexible to navigate delicate pediatric nasopharyngeal cavities. We describe a novel use of maxillofacial CT scans to aid in the design of pediatric nasopharyngeal swabs.

Characterization of Neurodevelopmental Abnormalities in iPSC-Derived Striatal Cultures from Patients with Huntington's Disease

Background:

Huntington’s disease (HD) is an inherited neurodegenerative disease and is characterized by atrophy of certain regions of the brain in a progressive manner. HD patients experience behavioral changes and uncontrolled movements which can be primarily attributed to the atrophy of striatal neurons. Previous publications describe the models of the HD striatum using induced pluripotent stem cells (iPSCs) derived from HD patients with a juvenile onset (JHD). In this model, the JHD iPSC-derived striatal cultures had altered neurodevelopment and contained a high number of nestin expressing progenitor cells at 42 days of differentiation.

Objective:

To further characterize the altered neurodevelopmental phenotype and evaluate potential phenotypic reversal.

Methods:

Differentiation of human iPSCs towards striatal fate and characterization by means of immunocytochemistry and stereological quantification.

Results:

Here this study demonstrates a distinct delay in the differentiation of the JHD neural progenitor population. However, reduction of the JHD aberrant progenitor populations can be accomplished either by targeting the canonical Notch signaling pathway or by treatment with HTT antisense oligonucleotides (ASOs).

Conclusions:

In summary, this data is postulated to reflect a potential overall developmental delay in JHD.

Coronavirus Disease 2019 in Children Cared for at Texas Children's Hospital: Initial Clinical Characteristics and Outcomes

We describe the clinical course of 57 children with coronavirus disease 2019 (COVID-19) cared for through a single hospital system. Most children were mildly symptomatic, and only a few patients with underlying medical conditions required hospitalization. Systemwide patient evaluation processes allowed for prompt identification and management of patients with COVID-19.

Strategies to Improve Recruitment to a De-escalation Trial: A Mixed-Methods Study of the OPTIMA Prelim Trial in Early Breast Cancer

AIMS

De-escalation trials are challenging and sometimes may fail due to poor recruitment. The OPTIMA Prelim randomised controlled trial (ISRCTN42400492) randomised patients with early stage breast cancer to chemotherapy versus 'test-directed' chemotherapy, with a possible outcome of no chemotherapy, which could confer less treatment relative to routine practice. Despite encountering challenges, OPTIMA Prelim reached its recruitment target ahead of schedule. This study reports the root causes of recruitment challenges and the strategies used to successfully overcome them.

MATERIALS AND METHODS

A mixed-methods recruitment intervention (QuinteT Recruitment Intervention) was used to investigate the recruitment difficulties and feedback findings to inform interventions and optimise ongoing recruitment. Quantitative site-level recruitment data, audio-recorded recruitment appointments (n = 46), qualitative interviews (n = 22) with trialists/recruiting staff (oncologists/nurses) and patient-facing documentation were analysed using descriptive, thematic and conversation analyses. Findings were triangulated to inform a 'plan of action' to optimise recruitment.

RESULTS

Despite best intentions, oncologists' routine practices complicated recruitment. Discomfort about deviating from the usual practice of recommending chemotherapy according to tumour clinicopathological features meant that not all eligible patients were approached. Audio-recorded recruitment appointments revealed how routine practices undermined recruitment. A tendency to justify chemotherapy provision before presenting the randomised controlled trial and subtly indicating that chemotherapy would be more/less beneficial undermined equipoise and made it difficult for patients to engage with OPTIMA Prelim. To tackle these challenges, individual and group recruiter feedback focussed on communication issues and vignettes of eligible patients were discussed to address discomforts around approaching patients. 'Tips' documents concerning structuring discussions and conveying equipoise were disseminated across sites, together with revisions to the Patient Information Sheet.

CONCLUSIONS

This is the first study illuminating the tension between oncologists' routine practices and recruitment to de-escalation trials. Although time and resources are required, these challenges can be addressed through specific feedback and training as the trial is underway.

High prevalence of albuminuria amongst people who inject drugs: A cross-sectional study

Albuminuria is a key biomarker for cardiovascular disease and chronic kidney disease. Our study aimed to describe the prevalence of albuminuria amongst people who inject drugs in London and to test any potential associations with demographic characteristics, past diagnoses, and drug preparation and administration practices. We carried out a cross-sectional survey amongst people who use drugs in London. The main outcome measure was any albuminuria including both microalbuminuria and macroalbuminuria. Three-hundred and sixteen samples were tested by local laboratory services. Our study initially employed point-of-care testing methods but this resulted in a high number of false positives. Our findings suggest the prevalence of albuminuria amongst PWID is twice that of the general population at 19% (95%CI 15.3–24.0%). Risk factors associated with albuminuria were HIV (aOR 4.11 [95% CI 1.37–12.38]); followed by overuse of acidifier for dissolving brown heroin prior to injection (aOR 2.10 [95% CI 1.04–4.22]). Albuminuria is high amongst people who inject drugs compared to the general population suggesting the presence of increased cardiovascular and renal pathologies. This is the first study to demonstrate an association with acidifier overuse. Dehydration may be common amongst this population and may affect the diagnostic accuracy of point-of-care testing for albuminuria.

Prediction of a positive circumferential resection margin at surgery following neoadjuvant chemotherapy for adenocarcinoma of the oesophagus

Background

A positive circumferential resection margin (CRM) has been associated with higher rates of locoregional recurrence and worse survival in oesophageal cancer. The aim of this study was to establish if clinicopathological and radiological variables might predict CRM positivity in patients who received neoadjuvant chemotherapy before surgery for oesophageal adenocarcinoma.

Methods

Multivariable analysis of clinicopathological and CT imaging characteristics considered potentially predictive of CRM was performed at initial staging and following neoadjuvant chemotherapy. Prediction models were constructed. The area under the curve (AUC) with 95% confidence intervals (c.i.) from 1000 bootstrapping was assessed.

Results

A total of 223 patients were included in the study. Poor differentiation (odds ratio (OR) 2·84, 95 per cent c.i. 1·39 to 6·01) and advanced clinical tumour status (T3-4) (OR 2·93, 1·03 to 9·48) were independently associated with an increased CRM risk at diagnosis. CT-assessed lack of response (stable or progressive disease) following chemotherapy independently corresponded with an increased risk of CRM positivity (OR 3·38, 1·43 to 8·50). Additional CT evidence of local invasion and higher CT tumour volume (14 cm3) improved the performance of a prediction model, including all the above parameters, with an AUC (c-index) of 0·76 (0·67 to 0·83). Variables associated with significantly higher rates of locoregional recurrence were pN status (P = 0·020), lymphovascular invasion (P = 0·007) and poor response to chemotherapy (Mandard score 4-5) (P = 0·006). CRM positivity was associated with a higher locoregional recurrence rate, but this was not statistically significant (P = 0·092).

Conclusion

The presence of advanced cT status, poor tumour differentiation, and CT-assessed lack of response to chemotherapy, higher tumour volume and local invasion can be used to identify patients at risk of a positive CRM following neoadjuvant chemotherapy.

1520. Streptococcus anginosus Group Organisms Are an Increasing Cause of Complicated Sinusitis and Otitis Media in Children

Background

The Streptococcus anginosus group (SAG), including S. anginosus, S. intermedius and S. constellatus, are common flora of the oral cavity, respiratory tree and gastrointestinal tract. However, these organisms have the potential to cause serious invasive infections and are notably pyogenic. We observed an apparent increase in the frequency of intraorbital and intracranial infections resulting from SAG at Texas Children’s Hospital (TCH). We undertook a retrospective review to describe the frequency and clinical features of these infections.

Methods

We reviewed the database of the clinical microbiology laboratory at TCH from 2011 to 2018 for SAG-positive cultures. For purposes of this study, cases included were those associated with 1) either otitis media or sinusitis and 2) Pott’s Puffy Tumor, orbital abscesses, epidural abscesses, subdural empyema, brain parenchymal abscesses, dural enhancement by imaging or mastoiditis. Similar methods were used for SAG identification throughout the study period. The number of cases per year was used along with annual hospital admissions data to estimate case rate; case rate trends were examined using linear regression.

Results

950 cultures positive for SAG were identified by the clinical lab; 95 cases met inclusion criteria. The median age of patients was 11.4 years. Specific diagnoses are presented in Figure 1. S. intermedius was most commonly isolated (81.1%) followed by S. constellatus (12.6%) and S. anginosus (7.4%); 50.5% of cases were polymicrobial. Among polymicrobial cases, S. aureus was most frequently isolated (25%). All patients underwent surgical intervention and 20.5% underwent ≥2 procedures (Figure 2). 16.8% were associated with intracranial thromboses and 4.2% with CNS infarcts; 8.4% of patients experienced persistent neurologic deficits. All isolates were susceptible to penicillin. We observed an increase in the annual disease rate during the study (Figure 3, P = 0.01).

Conclusion

Complications of otitis media and sinusitis due to SAG are associated with substantial morbidity. These infections are becomingly increasingly common at our center although the precise reason for this temporal trend is unclear. Multicenter studies are needed to validate these epidemiologic findings.

Disclosures

All authors: No reported disclosures.

P09.07 Constitutive activation of the EGFR-STAT1 axis increases proliferation of meningioma tumour cells

BACKGROUND

Meningiomas are the most frequent primary brain tumours of the central nervous system. The standard of treatment is (radio)surgery, but the lack of knowledge of their tumorigenesis contributes to delay the development of additional therapeutic options.

MATERIAL AND METHODS

We used a variety of differen model systems and cell biology techniques

RESULTS

We found STAT1 widely overexpressed in meningioma tumours and in patient-derived meningioma cells but not in the corresponding healthy controls. The protein showed a constitutive phosphorylation on both phosphosites (Y701 and S727), which was not dependent on the JAK/STAT pathway. STAT1 knocked down resulted in a significant reduction of cellular proliferation, showed as a decrease in Ki67-positive cells and Cyclin D1, and deactivation of AKT and ERK 1/2. By studying STAT1 binding partners we isolated a complex composed by STAT1, STAT2, PRMT5 and MEP50. As PRMT5 is known to interact with EGFR, we tested the tyrosine kinase and found that EGFR was constitutively active in meningioma and was responsible for the aberrant phosphorylation of STAT1 on both phosphosites. We tested different drugs inhibiting of EGFR phosphorylation, Canertinib was most effective. It caused a significant reduction in meningioma cells proliferation and a reduction of overall levels of Cyclin D1, phospho- AKT and phospho-ERK 1/2. Hence, STAT1 constitutive phosphorylation, initiated by EGFR activation, is responsible for inducing a positive feedback loop causing its own overexpression and consequently an increased proliferation of the tumour cells.

CONCLUSION

These findings underline a pivotal role of the EGFR and STAT1 axis in meningioma and provides the rationale for further studies aiming to identify novel and effective therapeutic options.

Chemical Composition and Antioxidant Properties of Essential Oils from Peppermint, Native Spearmint and Scotch Spearmint

Natural antioxidants have drawn growing interest for use in animal feed and the food industry. In the current study, essential oils (EOs) obtained from hydrodistillation of three mentha species, including Mentha piperita (peppermint), Mentha spicata (native spearmint) and Mentha gracilis (Scotch spearmint), harvested in the Midwest region in the United States, were analyzed for their chemical composition using gas chromatography-mass spectrometry, and their antioxidant properties were assessed through chemical assays, in vitro cell culture modeling and in Caenorhabditis elegans (C. elegans). The activity of ferric iron reduction and free-radical scavenging capacity were assessed through chemical-based assays, including the reducing power assay, 2,2-diphenyl-1-picrylhydrazyl (DPPH) radical scavenging assay, and Trolox equivalent antioxidant capacity assay (TEAC). Subsequently, the capacity of EOs to mitigate lipid peroxidation was analyzed at various doses using fresh liver homogenates from pigs. A porcine jejunum epithelial cell line (IPEC-J2) was employed as in vitro model to study the cellular antioxidant activity of the mint EOs. Finally, the effectiveness of mint EOs to alleviate acute systemic oxidative damage were evaluated in vivo using C. elegans. Data were analyzed by the MIXED procedure of SAS. Contrast statement was performed to assess linear or quadratic effects of mint EOs given at various doses. All three EOs are mostly composed of monoterpenes and their derivatives (76-90%), but differed in the major compounds, which are menthol and menthone (50%) in peppermint EO and carvone (70%) in spearmint EOs. Three mint EOs demonstrated prominent radical scavenging and Fe³⁺ reducing activity in chemical-based assays. In comparison with native and Scotch spearmint EOs, peppermint EO had the lowest (p < 0.05) half maximal effective concentration (EC50) in DPPH and TEAC assays and higher efficacy in the reducing power assay. All three EOs exhibited equivalent activity in mitigation of chemical-induced lipid peroxidation in liver tissues in a dose-dependent manner (linear, p < 0.001). The maximal cellular antioxidant activity (CAA) was observed at 5 µg/mL for peppermint, and 100 µg/mL for native and Scotch spearmint EOs. The addition of 25 µg/mL of both spearmint EOs increased (p < 0.05) cellular concentrations of glutathione in H₂O₂-treated IPEC-J2 cells, suggesting enhanced endogenous antioxidant defense. Supplementation of 100 µg/mL of peppermint or Scotch spearmint EO significantly increased (p < 0.05) the survival rate of C. elegans in response to H₂O₂-induced oxidative stress. The protective effect is comparable to that of supplementation of 10 µg/mL of ascorbic acid. However native spearmint EO failed to reduce the death rate within the same supplementation dose (10-200 μg/mL).

Clinical Importance of Placental Testing among Suspected Cases of Congenital Zika Syndrome

Contemporaneous Zika virus (ZIKV) strains can cause congenital Zika syndrome (CZS). Current ZIKV clinical laboratory testing strategies are limited and include IgM serology (which may wane 12 weeks after initial exposure) and nucleic acid testing (NAT) of maternal serum, urine, and placenta for (+) strand ZIKV RNA (which is often transient). The objectives of this study were to determine if use of additional molecular tools, such as quantitative PCR and microscopy, would add to the diagnostic value of current standard placental ZIKV testing in cases with maternal endemic exposure and indeterminate testing. ZIKV RNA was quantified from dissected sections of placental villi, chorioamnion sections, and full cross-sections of umbilical cord in all cases examined. Quantitation with high-resolution automated electrophoresis determined relative amounts of precisely verified ZIKV (74-nt amplicons). In order to localize and visualize stable and actively replicating placental ZIKV in situ, labeling of flaviviridae glycoprotein, RNA ISH against both (+) and (⁻) ZIKV-specific ssRNA strands, and independent histologic examination for significant pathologic changes were employed. We demonstrate that the use of these molecular tools added to the diagnostic value of placental ZIKV testing among suspected cases of congenital Zika syndrome with poorly ascribed maternal endemic exposure.

Palatine tonsil SUVmax on FDG PET-CT as a discriminator between benign and malignant tonsils in patients with and without head and neck squamous cell carcinoma of unknown primary

AIM

To analyse the maximum standardised uptake value (SUVmax) ratio between tonsils in patients with and without tonsillar carcinoma to determine useful diagnostic thresholds.

MATERIALS AND METHODS

Positron-emission tomography (PET)/computed tomography (CT) examinations of patients with suspected head and neck squamous cell carcinoma (SCC) and controls from April 2013 to September 2016 were reviewed retrospectively. Tonsillar SUVmax ratios (ipsilateral/contralateral for malignant tonsils, maximum/minimum for patients without [controls]) were calculated and used to construct a receiver operating characteristic (ROC) curve.

RESULTS

Twenty-five patients had tonsillar carcinoma (mean SUVmax ratio of 2, range 0.89-5.4) and 86 patients acted as controls (mean SUVmax ratio of 1.1, range 1-1.5). Using the ROC, the most accurate SUVmax ratio for identifying malignancy was >1.2 (77% sensitivity, 86% specificity). A potentially more clinically useful SUVmax ratio is ≥1.6 with 62% sensitivity and 100% specificity.

CONCLUSION

An SUVmax ratio between tonsils of ≥1.6 is highly suspicious for SCC and could be used to direct site of biopsy. Some malignant tonsils had normal FDG uptake; therefore, PET/CT should not be used to exclude tonsillar cancer. Minor asymmetrical uptake is frequently seen in non-malignant tonsils and does not necessarily require further investigation. Due to the single centre nature of this study and the recognised variation in SUV measurements between PET scans, other centres may need to develop their own cut-offs.

2308. The Prevalence of Antiseptic Tolerance Genes Among Gram-Positive Bloodstream Pathogens in Children

Background

The presence of the smr and qacA/B genes in Staphylococcus aureus have been correlated with reduced susceptibility to antiseptics. Recently, S. aureus bearing these genes have been reported to be associated with nosocomial acquisition of infection and underlying medical conditions. Antiseptic tolerance (AT) genes have also been reported in coagulase negative staphylococci (CoNS) and enterococci; however, little data are available regarding their prevalence. We sought to describe the frequency of smr and qacA/B among bloodstream isolates of S. aureus, CoNS and enterococci obtained at Texas Children’s Hospital (TCH).

Methods

Banked CoNS, S. aureus and enterococci isolated from blood cultures collected from October 1, 2016 to October 1, 2017 were obtained from the TCH clinical microbiology laboratory. All isolates underwent PCR for the qacA/B and smr genes. CoNS and enterococci were identified to the species level with MALDI-TOF mass spectrometry. Medical records were reviewed for all cases; CoNS were considered true pathogens if >1 blood culture was positive.

Results

268 CoNS, 19 Enterococcus spp. and 116 S. aureus isolates were identified and included (Figure 1). 83.2% of CoNS possessed at least one AT gene compared with 36.2% of S. aureus and 31.5% of enterococci (P < 0.001, Figure 2). Neither antiseptic gene was detected in E. faecium isolates (n = 4) compared with 43.8% of E. faecalis (P = 0.2). Among CoNS, methicillin-resistance was found more commonly among qacA/B-positive (77.2% vs. 40%, P = 0.04) and smr-positive isolates (93.8% vs. 60.5%, P = 0.02). 38.4% of CoNS bloodstream isolates were considered true infections; among these, the presence of either AT gene was strongly associated with nosocomial infection (P < 0.001). AT genes in S. aureus were associated with nosocomial infection (P = 0.007) as well as the diagnosis of CLA-BSI (P = 0.001). There was no correlation with genotypic AT in enterococci and any examined clinical variable.

Conclusion

AT is common among bloodstream staphylococci and E. faecalis isolates at TCH. Among CoNS, the presence of AT genes is strongly correlated with nosocomial acquisition of infection consistent with previous studies in S. aureus. These data suggest that the healthcare environment contributes to AT among staphylococci.

Disclosures

All authors: No reported disclosures.

2084. Prospective, Multi-Center Analysis of a BioFire® FilmArray® Childhood Systemic Infection (CSI) Panel for Detection of Viral Bloodstream Infections in a Pediatric Emergency Department Setting

Background

Early determination of viral etiology among febrile children with suspicion of systemic infection by use of rapid molecular assay could impact patient care. BioFire^® FilmArray^® Childhood Systemic Infection (CSI) Panel is a non-FDA cleared research use only sample-to-answer PCR-based assay that includes identification of seven viruses from 200 µl of whole blood collected from children suspected of systemic infection. The aim of this prospective multicenter study was to determine the viral diagnostic yield and potential impact of CSI panel on management of pediatric sepsis.

Methods

Children <18 years with suspected systemic infections were prospectively enrolled in emergency rooms at seven healthcare facilities. Febrile children with a clinician order of blood culture for sepsis evaluation were enrolled and additional blood was collected with the standard of care (SOC) blood culture. Blood samples were tested by the CSI Panel on the FilmArray platform. Demographic and laboratory test results from SOC blood, urine and cerebrospinal fluid (CSF) cultures were recorded.

Results

Among 1,022 children enrolled, data for 1,002 was complete. The CSI Panel testing of whole blood detected 203 (20%) viral infections including 14 (7%) with dual/multiple viruses. The median age of children with viral detections (20 months) was significantly lower than children without viral detections (54 months) (P < 0.01).The viruses detected were enterovirus (54%), adenovirus (22%), cytomegalovirus (15%), parvovirus B19 (15%) and parechovirus (3%). Herpes simplex virus 1 and 2 were not detected. Among 203 positive and 799 negative viral detections with the CSI Panel, blood culture was positive in 2 (1%) and 24 (3%) children respectively (P = 0.14). All CSF bacterial cultures ordered were negative. Urine culture was positive in 7/83 (8.4%) and 31/266 (11.7%) viral positive and negative children respectively (P = 0.55).

Conclusion

The CSI Panel detected virus in blood from 20% of febrile children suspected of systemic infection. Concurrent bacterial infection of blood and urine was lower in children that were viral positive vs. negative. Prompt determination of viral etiology using the CSI Panel has the potential to optimize care of children with suspected systemic infection.

Disclosures

N. Kanwar, Biofire Diagnostics: Collaborator, Research grant. J. Dien Bard, BioFire Diagnostics: Research Contractor, Research support. A. Leber, Nationwide Children’s Hospital: Research Contractor, Research support. J. Dunn, BioFire: Investigator, Research support. K. C. Chapin, Biofire: Research Contractor, Research support. C. A. Rostad, Biofire Diagnostics: Collaborator, Research support. A. J. Blaschke, BIoFire Diagnostics, LLC: I have intellectual property licensed to BioFire through the University of Utah, Independent Contractor and Investigator, Consulting fee, Licensing agreement or royalty and Research support. M. Jones, BioFire Dx: Employee, Salary. E. Ott, BioFire Diagnostics: Employee, Salary. J. Bastar, BioFire Diagnostics, LLC.: Employee, Salary. R. Selvarangan, BioFire Diagnostics: Investigator and Scientific Advisor, Consulting fee, Research support and Speaker honorarium.

Geographical Variations in the Clinical Management of Colorectal Cancer in Australia: A Systematic Review

Background: Colorectal cancer (CRC) presents considerable health, economic, and societal burden, and Australia has one of the highest incidence rates of this disease. Over a third of the Australian population live in nonmetropolitan areas and research has shown that they experience a range of health disadvantages that result in a higher disease burden and lower life expectancy. One of the main contributors of poorer CRC outcomes in rural Australia may be limited access to treatment facilities and optimal care; however, the extent to which geographical disparities exist in CRC management has not been systematically explored. Aim: To understand the nature of geographical variations in the clinical management and treatment of CRC (including surgery, chemotherapy, and radiotherapy) in Australia, incorporating clinical reports as well as peer-reviewed literature. Methods: A systematic review of published and gray literature was conducted. Five databases (CINAHL, PubMed, Embase, ProQuest, and Informit) were searched for articles published in English from 1990 to 2018. Studies were included if they assessed differences in clinical management according to geographical location; focused on CRC patients; and were conducted in Australia. Included studies were critically appraised using a modified Newcastle-Ottawa Scale. PRISMA systematic review reporting methods were applied. Results: Only 17 articles met inclusion criteria. All were of high (53%) or moderate (47%) quality. The evidence available may suggest that patients in nonmetropolitan areas are more likely to experience delays in surgery and are less likely to receive chemotherapy for stage III colon cancer and adjuvant radiotherapy for rectal cancer. Conclusion: The present review found limited information on clinical management across geographic regions in Australia and the synthesis highlights significant issues both for data collection and reporting at the population level. Where geographical disparities exist, these may be due to a combination of patient and system factors reflective of location. Population-level data regarding clinical management and treatment of CRC needs to be routinely collected to better understand geographical variations and inform future guidelines and policy.

Developing a Nurse-Led Intervention for Men With Advanced Prostate Cancer: A Preimplementation Study

Background: Men with advanced prostate cancer can experience poor life quality and health outcomes compared with men with localized disease. Closely matching men's needs and identifying barriers and facilitators to implementation were critical first steps for ensuring the feasibility of our nurse-led telephone-based supportive care intervention for men with advanced prostate cancer. Aim: The aim of this study is to understand the context for implementing ProsCare from PCSNs, and in doing so, further develop the intervention and implementation strategy. Methods: A total of 30 Prostate Cancer Specialist Nurses (PCSNs) participated in 4 semistructured focus groups. Data were coded into the Consolidated Framework for Implementation Research (CFIR) to evaluate the ProsCare program content and guide the implementation and evaluation of this targeted program for men with advanced prostate cancer. Results: Participants validated ProsCare components of (1) decision support; (2) treatment education with self-management and skills training for symptom effects, including exercise prescription; (3) routine screening for psychological distress with referral; (4) psycho-education with tailored distress management strategies; and (5) communicating with health professionals. Data supported a revised treatment schedule and a comprehensive implementation plan including professional education and centralised administration. Conclusion: ProsCare is a valid supportive care nurse-led intervention. The CFIR framework is useful for the structured identification of implementation factors.

Challenges and Opportunities for Cancer Care in Regional Australia: The Health Professional´s Perspective

Background: Cancer specialists working in rural and regional Australia may experience unique difficulties when compared with their metropolitan counterparts, as they often have higher workloads, spend longer hours in clinical practice, and experience professional and social isolation. Previous research has identified accessibility and distance from services, a shortage of workforce, limited availability of specialists and allied health providers, suboptimal chemotherapy administration, and reduced availability of radiotherapy services as predictors of poorer outcomes in regional areas. Yet to date, limited research has focused on the perspective of the regional healthcare professionals. Aim: This study aimed to identify the factors which health professionals believe influence clinical care and outcomes for people with cancer in regional areas of Australia, to confirm existing barriers and identify any new insights specific to the health professional perspective. Methods: Semistructured interviews were conducted with regional oncology health professionals of varying backgrounds. Interview questions explored health professional´s perspectives on barriers to cancer care for patients, factors which influence clinical care, and access to support in regional areas. Data were interpreted using an inductive thematic analysis approach. Results: Two global themes were identified: rural culture and the health system. Within these global themes, health professionals discussed barriers to cancer care in regional areas, predominantly associated with travel, limited workforce, and poor communication within the health system. Participants also noted many positive aspects of cancer care in regional areas, including more personalised care for the patients and faster career progression for professionals. Conclusion: Despite recent innovations aimed at improving rural cancer care, including innovative models of care and increased infrastructure, regional health professionals still perceive many barriers to cancer care in regional Australia. These are predominantly associated with patient demographics, travel difficulties, and inadequate governance. However, there are also many notable benefits to receiving care in regional areas which have been absent from previous literature. These positive factors should be incorporated in efforts to enhance regional cancer care through the recruitment of health professionals to regional areas and development of regional community support networks. An understanding of the experiences of health professionals working in oncology settings in regional areas is a key step toward improving care and providing recommendations to health services and policymakers, particularly regarding recruitment and retention.

Geographic Variation in Compliance With FOBT Colorectal Cancer Screening Programs: The Role of Attitudes Toward Health and Help Seeking

Background: Utilization of health services is thought to vary between urban and nonurban residents. In Australia, colorectal cancer (CRC) patients in peri-urban and rural areas tend to be diagnosed at a more advanced stage than their urban counterparts and have poorer 5 year survival rates. Aim: In this study, we investigate the effect that attitudes toward health and health related help-seeking have on compliance with population CRC screening programs and whether this varied among varied locations. We also examined the rate of recipients complying with overall program guidelines as opposed to the commonly reported participation rates in mail-out screening programs. Methods: A cross-section of recipients (n=371) who reported receiving a mail-out fecal occult blood test (FOBT) as part of the National Bowel Cancer Screening Program (NBCSP) in Australia were surveyed in 2017 regarding compliance. Attitudinal constructs including fatalism, stoicism and consideration of future consequences known to impact health-related help seeking were also measured. Logistic regression models were tested to assess the attitudinal predictors of program compliance in urban, peri-urban and rural groups. Results: Program participation (% returning kits) was relatively even across geographical locations, however, compliance with overall screening guidelines (returning kit or engaging in suitable alternative) was significantly lower in peri-urban, compared with urban, areas. Higher levels of stoicism and lower levels of consideration for future consequences were associated with lower NBCSP compliance in rural and peri-urban, but not urban areas. Fatalism was not associated with NBCSP compliance. Conclusion: Attempts to increase compliance with mail-out CRC screening program guidelines need to consider the use of appropriately tailored interventions that reflect the different ways in which socio-cultural and psychological factors impact cancer screening practices in geographically diverse communities. Interventions to enhance compliance in nonurban areas should promote the consideration of one's future, and discourage stoic attitudes to health.

Strategies for Increasing Participation in Mail-out Colorectal Cancer Screening Programs. A Systematic Review and Meta-Analysis

Background: Population mail-out bowel screening programs are a convenient, cost-effective and sensitive method of detecting colorectal cancer (CRC). Despite increased survival rates associated with early detection of CRC, in many countries 50% or more of eligible individuals do not participate in such programs, resulting in a substantial amount of cancers progressing undetected and wasted public health resources. Aim: The current study aimed to systematically review all of the interventions that have been applied internationally to increase fecal occult blood test (FOBT) kit return, specifically in population mail-out programs, to make recommendations to policy makers and program organizers as to the most effective methods of increasing uptake. Method: Six electronic databases (PubMed, PsycINFO, Scopus, InformIT, CINAHL, and ProQuest Dissertations and Theses) were searched for articles published in English before 10th of March 2018. Studies were included if they reported the results of an intervention designed to increase the return of FOBT kits that had been mailed to individuals' homes. Results: PRISMA systematic review reporting methods were applied and each study was assessed using Cochrane's risk of bias tool. The quality of evidence was assessed using GRADE guidelines. The review identified 53 interventions from 30 published studies. Nine distinct intervention strategy types were identified and pooled risk ratios and confidence intervals were estimated for each intervention type. Four key effective intervention strategies were identified including telephone contact, GP endorsement, simplified test procedures, and advance notification with small to moderate effect sizes. Conclusions: Interventions that combine program-level changes incorporating the issue of advance notification and alternative screening tools with the involvement of primary health professionals through endorsement letters and telephone contact should lead to increases in kit return in mail-out CRC screening programs. Future research should examine the benefit of combining intervention strategies and tailoring to specific populations.