Functional analysis of Rickettsia monacensis strain humboldt folA dihydrofolate reductase gene via complementation assay

Nutritive symbiosis between bacteria and ticks is observed across a range of ecological contexts; however, little characterization on the molecular components responsible for this symbiosis has been done. Previous studies in our lab demonstrated that Rickettsia monacensis str. Humboldt (strain Humboldt) can synthesize folate de novo via the folate biosynthesis pathway involving folA, folC, folE, folKP, and ptpS genes. In this study, expression of the strain Humboldt folA gene within a folA mutant Escherichia coli construct was used to functionally characterize the strain Humboldt folA folate gene in vivo. The strain Humboldt folA folate gene was subcloned into a TransBac vector and transformed into a folA mutant E. coli construct. The mutant containing strain Humboldt folA subclone and a pFE604 clone of the knocked-out folA gene was cured of pFE604. Curing of the folA mutant E. coli construct was successful using acridine orange and 43.5 °C incubation temperature. The plasmid curing assay showed curing efficiency of the folA mutant at 100%. Functional complementation was assessed by growth phenotype on minimal media with and without IPTG between strain Humboldt folA and E. coli folA. Large and homogenous wild-type colony growth was observed for both strain Humboldt and E. coli folA on minimal media with 0.1 mM IPTG, wild-type growth for strain Humboldt folA and pin-point growth for E. coli folA on 0.01 mM IPTG, and pin-point growth without IPTG for both strain Humboldt and E. coli folA. This study provides evidence substantiating the in vivo functionality of strain Humboldt folA in producing functional gene products for folate biosynthesis.

Long Term Evaluation of Cardiac Events and Outcomes Following Breast Cancer Irradiation

PURPOSE/OBJECTIVE(S)

Although whole heart dose has been associated with cardiac toxicity in patients receiving radiation therapy for breast cancer, data detailing the clinical significance of cardiac substructures, particularly the left anterior descending artery (LAD), are limited. We investigated whether dose to the LAD correlates with adverse cardiac events and death.

MATERIALS/METHODS

We identified 190 female patients treated from 2002 to 2019 who received breast or chest wall irradiation, with or without regional nodal irradiation. Ninety-three patients were treated on their right side, 95 on their left, and two were bilateral. Medical records were queried in healthcare software to identify cardiac events after radiation therapy. Mean and maximum LAD and heart doses, as well as V15LAD, were calculated. Univariate and multivariate Cox regression analyses were performed to determine their association with cardiac toxicity as well as death. Cumulative incidence curves for death and cardiac toxicity were also calculated for the patient population.

RESULTS

Median follow-up time was 68 months. Thirty patients experienced a cardiac event (15.7%), with three of these being grade 3 or higher. On univariate analyses, left side (hazard ratio 8, P<0.001), increased Mean LAD Dose per cGy (1.001, P = 0.01), Mean Heart Dose (1.16, P = 0.01), and anatomic stage (3.5, P = 0.003) were statistically significant predictors of death but not of adverse cardiac events. Statistically significant predictors of adverse cardiac events were the receipt of chemotherapy (2.68, p = 0.046) which remained significant even after adjusting for radiation parameters. There was no association with hormonal therapy use. Cumulative incidence curves predicted a 14.11% probability of a cardiac event 5 years after treatment and a 25.7% probability at 10 years after treatment. They also predicted a 9.43% probability of death at both 5- and 10-years post-treatment.

CONCLUSION

On this long-term analysis, doses to the heart seemed to negatively impact survival, but did not have a clear association between cardiac events. In contrast, utilizing cytotoxic systemic therapy seemed have an association, even when adjusted for on multivariable models for cardiac events.

Single-Pulse Transcranial Magnetic Stimulation for the preventive treatment of difficult-to-treat migraine: a 12-month prospective analysis

BACKGROUND

Initial evidence have shown the short-term efficacy of sTMS in the acute and preventive treatment of migraine. It is unknown whether this treatment approach in the long-term is effective and well tolerated in difficult-to-treat migraine.

METHODS

This is a prospective, single centre, open-label, real-world analysis conducted in difficult-to-treat patients with high-frequency episodic migraine (HFEM) and chronic migraine (CM) with and without medication overuse headache (MOH), who were exposed to sTMS therapy. Patients responding to a three-month sTMS treatment, continued the treatment and were assessed again at month 12. The cut-off outcome for treatment continuation was reduction in the monthly moderate to severe headache days (MHD) of at least 30% (headache frequency responders) and/or a ≥ 4-point reduction in headache disability using the Headache Impact test-6 (HIT-6) (headache disability responders).

RESULTS

One hundred fifty-three patients were included in the analysis (F:M = 126:27, median age 43, IQR 32.3-56.8). At month 3, 93 out of 153 patients (60%) were responders to treatment. Compared to baseline, the median reduction in monthly headache days (MHD) for all patients at month 3 was 5.0 days, from 18.0 (IQR: 12.0-26.0) to 13.0 days (IQR: 5.75-24.0) (P = 0.002, r = - 0.29) and the median reduction in monthly migraine days (MMD) was 4.0 days, from 13.0 (IQR: 8.75-22.0) to 9.0 (IQR: 4.0-15.25) (P = 0.002, r = - 0.29). Sixty-nine out of 153 patients (45%) reported a sustained response to sTMS treatment at month 12. The percentage of patients with MOH was reduced from 52% (N = 79/153) at baseline to 19% (N = 29/153) at month 3, to 8% (N = 7/87) at month 12. There was an overall median 4-point reduction in HIT-6 score, from 66 (IQR: 64-69) at baseline to 62 at month 3 (IQR: 56-65) (P < 0.001, r = - 0.51). A total of 35 mild/moderate adverse events were reported by 23 patients (15%). One patient stopped sTMS treatment due to scalp sensitivity.

CONCLUSIONS

This open label analysis suggests that sTMS may be an effective, well-tolerated treatment option for the long-term prevention of difficult-to-treat CM and HFEM.

Ivabradine: pre-clinical and clinical evidence in the setting of ventricular arrhythmias

BACKGROUND

Ivabradine, an agent lowering the heart rate, acting as a funny current (If) specific inhibitor, is responsible for the sinoatrial node's spontaneous depolarization. According to current guidelines, it is indicated in specific heart failure populations and as a second-line treatment option to improve angina in chronic coronary syndromes.

REVIEW OF LITERATURE

The role of ivabradine in the setting of ventricular arrhythmias has been studied in both experimental and clinical studies. Specifically, experimental studies have examined the role of ivabradine in acute myocardial ischemia, reperfusion, digitalis-induced ventricular arrhythmias, and catecholaminergic polymorphic ventricular tachycardia showing promising results. In addition, clinical studies have shown a beneficial role of ivabradine in reducing ventricular arrhythmias. Ivabradine reduced premature ventricular contractions in combination with beta-blockers in dilated cardiomyopathy patients. Similarly, in catecholaminergic polymorphic ventricular tachycardia, ivabradine reduced dobutamine-induced premature ventricular complexes and improved ventricular arrhythmias burden. On the other hand, current data show no beneficial role of ivabradine in reducing ventricular arrhythmias in myocardial ischemia.

CONCLUSIONS

Randomized clinical trials are needed to elucidate the role of ivabradine in reducing the burden of ventricular arrhythmias in various clinical settings. HIPPOKRATIA 2022, 26 (2):49-54.

Development of an mHealth Intervention to Improve PrEP Knowledge Among Young Black Women in Family Planning Clinics (Preprint)

Background

Young Black women between the ages of 18 and 24 years are disproportionately impacted by HIV, yet they have a low self-perception of HIV risk and limited exposure to prevention strategies. Pre-exposure prophylaxis (PrEP) is a safe and effective biomedical HIV prevention strategy for those at risk for HIV infection, but uptake has been slow among cisgender women. Family planning clinics are a primary source of health care access for young women, providing an ideal opportunity to integrate PrEP information and care into existing clinic practices.

Objective

The aim of this study was to use a multistage, community-engaged process to develop a mobile health app and to evaluate the feasibility and acceptability of the app.

Methods

Using user-centered design, the In the Loop app was developed in collaboration with a community advisory board of young Black women. This study employed a multistage design, which included community-engaged app development, user testing, and evaluation of the app’s feasibility and acceptability. A pre- and postdesign was used to assess the impact of the app on PrEP knowledge immediately after app use. Descriptive statistics (eg, mean, SD, and percentage values) were used to describe the sample, and Wilcoxon matched-pairs signed-ranks test was used to detect changes in PrEP knowledge before and immediately after using the app.

Results

A total of 50 sexually active, young Black women, aged 18-24 (mean 21, SD 1.9) years, were enrolled in this study. Analysis comparing scores before and immediately after use of the app revealed a significant increase in PrEP content knowledge scores on a 7-item true or false scale (z=–6.04, P<.001). Overall, participants considered the In the Loop app feasible and acceptable to use while waiting for a family planning visit. The majority of participants (n=46, 92%) agreed that they would recommend In the Loop to friends to learn more about PrEP. Participants rated the overall quality of the app 4.3 on a 1-5 scale (1=very poor and 5=very good). Of 50 participants, 40 (80%) agreed that the app was easy to use, and 48 (96%) agreed that they found the information in the app easy to understand. Finally, 40 (80%) agreed that they had enjoyed using the app while waiting for their family planning visit.

Conclusions

Our findings suggest that young Black women waiting for family planning visits found the In the Loop app to be feasible and acceptable. This study demonstrates the value of engaging young Black women in the app design process. As family planning clinics are a primary source of health care access for young women, they provide an ideal setting to integrate PrEP information and care into existing clinic practices. Next steps in the development of the In the Loop app include implementing user-suggested improvements and conducting efficacy testing in a randomized controlled trial to determine the app’s impact on PrEP uptake.

The role of bystander-initiated basic life support in exercise-related sudden cardiac arrest: a systematic review

Background

Sudden cardiac arrest (SCA) is the leading cause of death amongst athletes and a common cause of death during exercise. Although the provision of cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use by bystanders improves outcomes after SCA, the impact of these interventions within exertional settings requires further investigation.

Purpose

The purpose of this systematic review was to evaluate the role of bystander CPR and AED use on survival after exercise-related SCA.

Methods

Literature searches in MEDLINE, EMBASE, PubMed, CINAHL, SPORTDiscus, and Cochrane Library were queried from inception until November 2020 using a comprehensive search strategy. Grey literature searches of Google Scholar and CADTH Grey Matters were also performed. Abstract screening, full-text review, and data extraction of eligible studies was conducted independently by two reviewers, with any conflicts discussed until consensus reached. Eligible studies included observational research studies assessing a population of exercise-related SCAs (defined as an out-of-hospital cardiac arrest which occurred during exercise or within 1-hour of cessation of activity), where the rate of bystander CPR and/or AED use was provided, and survival outcomes were reported. Abstracts, studies with overlapping patient data, and/or studies of n≤10 were excluded. Among studies with similar populations, the overall rates (median, range) of bystander CPR, AED use, and survival outcomes were calculated.

Results

A total of 3,718 records were identified from literature searches, and after removal of duplicates, 2,850 were screened. Among those screened, 176 articles were selected for full-text review, of which 29 studies were included in this review. Majority of included studies were cohort studies (2 case series and 2 cross-sectional), with a median sample size of 91. Most patients who suffered from an exercise-related SCA were male, middle-aged, and presented with a shockable arrest rhythm. The median rate of bystander CPR reported amongst 22 studies was 71% (31%-100%), whereas the median rate of bystander AED use reported amongst 16 studies was 31% (2%-100%) (Table). Among the 19 studies which reported the rate of survival to hospital discharge, survival ranged from 11% to 77%, with a median rate of 32% (Table). Patients who survived to hospital discharge more frequently received bystander CPR and had an AED applied than patients who died (Figure).

Conclusions

Survival rates after exercise-related SCA were higher than previously reported in other settings not related to exercise. These outcomes are likely related to a higher rate of bystander interventions in exertional or sport-specific settings. The findings of this review encourage layperson education in basic life support, the availability of AEDs in exercise facilities, and the development of emergency action plans to provide point-of-performance cardiac care in exertional settings.

Funding Acknowledgement

Type of funding sources: None.

Unusual Near-Horizon Cosmic-Ray-like Events Observed by ANITA-IV

ANITA's fourth long-duration balloon flight in 2016 detected 29 cosmic-ray (CR)-like events on a background of 0.37_{-0.17}^{+0.27} anthropogenic events. CRs are mainly seen in reflection off the Antarctic ice sheets, creating a phase-inverted waveform polarity. However, four of the below-horizon CR-like events show anomalous noninverted polarity, a p=5.3×10^{-4} chance if due to background. All anomalous events are from locations near the horizon; ANITA-IV observed no steeply upcoming anomalous events similar to the two such events seen in prior flights.

A Pragmatic Randomized Controlled Trial to Increase PrEP Uptake for HIV Prevention: 55-Week Results From PrEPChicago

OBJECTIVES

We tested preliminary efficacy of a peer change agent type I network intervention to increase pre-exposure prophylaxis (PrEP) linkage to care among network members connected to young Black men who have sex with men.

DESIGN

Parent study is a pragmatic randomized controlled trial with 110 weeks of total follow-up. Interim midpoint analyses are performed here using participant data before crossover assignment at 55 weeks.

METHODS

We randomly assigned 423 participants in Chicago to receive the network intervention, an opinion leader workshop with telephonic booster sessions, versus a time-matched control from 2016 to 2018. The consolidated surrogate outcome was PrEP referral and linkage to clinical care among network members connected to study participants and was collected from independent administrative data.

RESULTS

Each study participant in the trial (n = 423) had on average 1822 network contacts who could be eligible for PrEP referral and linkage. During the 55-week observation period, PrEP referral was most likely to occur within 3 days of an intervention session compared to control [odds ratio (OR) 0.07 (0.02-0.013); P = 0.007] resulting in 1-2 referrals of network members per session. Network members with referral or linkage were more likely to be connected to study participants in the intervention arm than the control condition [aOR 1.50 (1.09-2.06); P = 0.012].

CONCLUSIONS

A peer change agent type I network intervention is preliminarily effective at diffusing PrEP through a network of individuals highly susceptible to HIV over 55 weeks. This low-intensity intervention demonstrated network-level impact among populations that have experienced limited PrEP care engagement in the United States.

1679. Evaluation of the Treatment of Urinalyses and Urine Cultures in Multiple Sclerosis Patients

Background

Patients with Multiple Sclerosis (MS) experience lower urinary tract dysfunction (LUTD) that in some cases, may necessitate catheterization. Discerning asymptomatic bacteriuria (ASB) from urinary tract infection (UTI) in MS patients is complicated by LUTD, leading to potentially inappropriate antimicrobial use. The purpose of this study was to evaluate the antimicrobial treatment practices of positive urine cultures in patients with MS.

Methods: A single-center, retrospective study. Positive cultures in patients with diagnosed MS (ICD10: G35) were included. The primary outcome was the proportion of patients that were appropriately treated with or without antimicrobial therapy. Secondary endpoints included antimicrobial selection and urinalysis obtainment and positivity.

Results

236 cultures from 139 patients were evaluated. Frequency, nocturia, dysuria, and foul-smelling urine were reported by patients in 54 (23%), 10 (4%), 25 (11%), and 14 (6%) of cases, respectively. Treatment was inappropriate in 81/201 (40%) of treated cultures. The agent selected was considered too broad in 35/201 (17%) instances. Of those, fluoroquinolones were the agents utilized in 33/35 (94%) cases. A urinalysis was sent in 200 (85%) cases, with 197/200 (99%) positive for at least one of four pre-defined positivity criteria.

Conclusion

Urinalyses and urine cultures are obtained frequently in patients with MS, often independent of patient symptomatology. Multiple sclerosis patients may be treated for ASB at higher rates than the general population, and traditional urinary symptoms may not be appropriate indicators of infection. Empiric therapy for UTI is frequently utilized in this population, often resulting in too broad of antimicrobial therapy.

Disclosures

All Authors: No reported disclosures

394. Pseudo-outbreak of Coagulase-negative Staphylococcus Species from Blood Cultures Highlights Unique Challenges in Care of Critically Ill Patients With COVID-19

Background

In response to the COVID-19 pandemic, a dedicated intensive care unit for patients infected with SARS-CoV-2 was created at our institution. We noticed a marked increase in the number of blood cultures positive for coagulase-negative Staphylococcus species (CoNS) that highlights unique challenges that arise with the creation of new units and workflows.

Methods

We reviewed all blood culture results from the COVID-19 intensive care unit (CoVICU) from April 15 to May 29. We reviewed all blood cultures taken from the oncology ward, medical intensive care unit (MICU), and emergency department (ED) for the same time frame as a comparison. We calculated contamination rates, using the clinical microbiology laboratory criteria for possible contaminants based on species and number of positive blood cultures.

Results

There were 324 total blood cultures collected from the CoVICU with 27/324 (8.3%) positive for organisms deemed contaminant, 10/324 (3.1%) were positive considered bloodstream infections (BSI); the ratio of BSI:contaminant was 1:2.7. For the MICU, ED, and oncology units contamination rates were 2/197 (1%), 33/747 (4.4%), and 2/334 (0.6%), respectively; and the ratio of BSI:contaminant was 5:1, 2.2:1, and 17.5:1, respectively. There was a significant relationship between contamination rates and unit, X²(3, N = 1602) = 30.85, p < 0.001.

Conclusion

Upon investigation, peripheral blood draw kits were not stocked in the CoVICU. Additionally, certain components of standard work for blood culture collection (e.g. glove exchange) could not be performed per usual practice due to isolation precautions. Peripheral blood draws were routinely performed by nurses in CoVICU and MICU while phlebotomy performed these in other comparison units. We suspect that lack of availability of blood draw kits and disruption of typical workflow in isolation rooms contributed to an unusually high number of contaminated blood cultures among patients admitted to the CoVICU. Notably, the CoVICU and MICU providers were the same pool of caregivers, further supporting a process issue related to isolation precautions. Institutions should be aware of the need for extra attention to supply chain management and examination of disruption to standard work that arise in the management of COVID-19 patients.

Disclosures

All Authors: No reported disclosures

90. Impact of Discrepant Rapid Diagnostic Test (RDT) Results on Antimicrobial Stewardship Program (ASP) Interventions in Patients with Bloodstream Infections (BSI) due to Gram-Negative Bacilli (GNB)

Background

Implementation of the Accelerate Pheno^TM Gram-negative platform (AXDX) paired with ASP intervention projects to improve time to definitive institutional-preferred antimicrobial therapy (IPT). However, few data describe the impact of discrepant RDT results from standard of care (SOC) methods on antimicrobial prescribing. Here we evaluate the prescribing outcomes for discrepant results following the first year of AXDX + ASP implementation.

Methods

Consecutive, non-duplicate blood cultures for adult inpatients with GNB BSI following combined RDT + ASP intervention were included (July 2018 – July 2019). AXDX results were emailed to the ASP in real time then released into the EMR upon ASP review and communication with the treating team. SOC identification (ID; Vitek® MS/Vitek® 2) and antimicrobial susceptibility testing (AST; Trek Sensititre^TM) followed RDT as the reference standard. IPT was defined as the narrowest susceptible beta-lactam, and a discrepancy was characterized when there was categorical disagreement between RDT and SOC methods. When IPT by AXDX was found to be non-susceptible on SOC, this was characterized as “false susceptible“. Conversely, “false resistance” was assessed when a narrower-spectrum agent was susceptible by SOC. Results were also deemed discrepant when the AXDX provided no/incorrect ID for on-panel organisms, no AST, or a polymicrobial specimen was missed.

Results

Sixty-nine of 250 patients (28%) had a discrepancy in organism ID or AST: false resistance (9%), false susceptible (5%), no AST (5%), no ID (4%), incorrect ID (2%), and missed polymicrobial (2%). A prescribing impact occurred in 55% of cases (Table 1), where unnecessarily broad therapy was continued most often. Erroneous escalation (7%) and de-escalation to inactive therapy (7%) occurred less frequently. In-hospital mortality occurred in 4 cases, none of which followed an inappropriate transition to inactive therapy.

Conclusion

Though the AXDX platform provides rapid ID and AST results, close coordination with Clinical Microbiology and continued ASP follow up are needed to optimize therapy. Although uncommon, the potential for erroneous ASP recommendations to de-escalate to inactive therapy following AXDX results warrants further investigation.

Disclosures

Amy J. Mathers, MD, D(ABMM), Accelerate Diagnostics (Consultant)

A Phase 2a Randomized, Double-Blind, Dose-Optimizing Study to Evaluate the Immunogenicity and Safety of a Bivalent DNA Vaccine for Hemorrhagic Fever with Renal Syndrome Delivered by Intramuscular Electroporation

Hantaan virus (HTNV) and Puumala virus (PUUV) are pathogenic hantaviruses found in Asia and Europe, respectively. DNA vaccines targeting the envelope glycoproteins of these viruses have been constructed and found to elicit neutralizing antibodies when delivered to humans by various technologies including intramuscular electroporation. Here, we report findings from a Phase 2a clinical trial of a combined HTNV/PUUV DNA vaccine delivered at varying doses and administration schedules using the Ichor Medical Systems TriGrid intramuscular electroporation delivery technology. The study was designed to characterize the effects of DNA vaccine dose and number of administrations on the frequency and magnitude of immunological response. Subjects (n = 120) were divided into four cohorts. Cohorts 1 and 2 received a dose of 2 mg of DNA (1 mg per plasmid), and cohorts 3 and 4 received a dose of 1 mg of DNA (0.5 mg per plasmid) each vaccination. Each of the four cohorts received a series of four administrations (days 0, 28, 56 and 168). For cohorts 1 and 3, the DNA vaccine candidate was delivered at each of the four administrations. For cohorts 2 and 4, in order to maintain blinding, subjects received the DNA vaccine on days 0, 56 and 168, but on day 28 received only the phosphate buffered saline vehicle rather the DNA vaccine. Sera were collected on days 0, 28, 56, 84, 140, 168, 196, 252 and 365 and evaluated for the presence of neutralizing antibodies by PUUV and HTNV pseudovirion neutralization assays (PsVNAs). Day 84 was also evaluated by a plaque reduction neutralization test (PRNT). Overall the PsVNA50 geometric mean titers (GMTs) and seropositivity rates among cohorts were similar. Cohort 3 exhibited the highest frequency of subjects that became seropositive to both PUUV and HTNV after vaccination, the highest peak GMT against both viruses, and the highest median titers against both viruses.

Enhanced Recovery after Surgery (ERAS) Protocols Expanded over Multiple Service Lines Improves Patient Care and Hospital Cost

Enhanced recovery after surgery (ERAS) may improve patients’ postoperative course. Our center implemented the ERAS protocol for the colorectal service in 2016, and then expanded to multiple service lines over the course of 1.5 years. Our aim was to determine whether broad implementation of ERAS protocols across different service lines could improve patient care. All ERAS patients from 2018 were captured prospectively. For each service line using ERAS, one full year of data preceding ERAS was compared. ERAS service lines included colorectal, gynecology laparoscopic, gynecology open, hepatopancreaticobiliary, urology – nephrectomy and cystectomy, spinal fusion, cardiac surgery—coronary artery bypass grafting. ERAS and pre-ERAS services were compared based on length of stay (LOS), complications, readmission, and mortality rates. In addition, hospital costs were collected during this time frame. ERAS protocols significantly decreased LOS for colorectal, gynecology, and spine. Complications were significantly decreased in colorectal, gynecology, urology, and spine. Readmissions did not significantly increase in any service line except spine. There was no significant change in mortality. ERAS proved to save the hospital 1847 days and cost saving of almost $5 million in 2018. Implementing ERAS broadly improved patient outcomes (LOS, complications, readmission, and mortality) while providing cost savings to the hospital.

The Perirolandic Sign: A Unique Imaging Finding Observed in Association with Polymerase γ-Related Disorders

Pathogenic variants in the polymerase γ gene (POLG) cause a diverse group of pathologies known as POLG-related disorders. In this report, we describe brain MR imaging findings and electroencephalogram correlates of 13 children with POLG-related disorders at diagnosis and follow-up. At diagnosis, all patients had seizures and 12 had abnormal MR imaging findings. The most common imaging findings were unilateral or bilateral perirolandic (54%) and unilateral or bilateral thalamic signal changes (77%). Association of epilepsia partialis continua with perirolandic and thalamic signal changes was present in 86% and 70% of the patients, respectively. The occipital lobe was affected in 2 patients. On follow-up, 92% of the patients had disease progression or fatal outcome. Rapid volume loss was seen in 77% of the patients. The occipital lobe (61%) and thalamus (61%) were the most affected brain regions. Perirolandic signal changes and seizures may represent a brain imaging biomarker of early-onset pediatric POLG-related disorders.

A prospective case series of sphenopalatine ganglion pulsed radiofrequency therapy for refractory chronic cluster headache

BACKGROUND AND PURPOSE

The management options for chronic cluster headache (CCH) are limited and a significant proportion of patients become refractory to pharmacological treatments. Pulsed radiofrequency (PRF) of the sphenopalatine ganglion (SPG) may present an efficacious, minimally invasive treatment modality for patients with refractory CCH. We describe the clinical outcomes of 14 patients with refractory CCH treated with PRF of the SPG.

METHODS

Patients with medically refractory CCH who underwent percutaneous SPG-PRF treatment between January 2016 and April 2019 were included in this report. Patients obtaining at least 30% reduction in weekly cluster attacks for at least 3 months were defined as responders. Treatment-related side effects were collected.

RESULTS

A total of 14 patients were included in this report (nine males). At a median follow-up of 6.5 (range 6-13) months post-procedure, eight patients (57.1%) were defined as responders to the treatment. Six patients were non-responders and reported either a reduction in frequency and severity of attacks for <3 months (2/6), no improvement (2/6) or temporary worsening of symptoms (1/6). The majority of patients (63.6%, n = 7/11) treated with >45 V were responders compared with responders treated with 45 V (33.3%, n = 1/3). Five patients (35.7%) experienced post-procedural side effects.

CONCLUSION

This case series suggests that PRF targeting the SPG might offer a safe, minimally invasive and effective treatment for medically refractory CCH. Given the small number of cases and the short follow-up, larger and more robust studies will be needed to confirm our findings.

Impact of select risk factors on treatment outcome in adults with candidemia

Background:

Studies examining relationships between patient-related factors and treatment outcome in patients with candidemia are limited and often based on all-cause mortality.

Objective:

Our purpose was to examine the impact of concurrent renal replacement therapy (RRT) and other pre-specified factors on treatment outcome among adults with candidemia.

Methods:

This Institutional Review Board (IRB)-approved, single-center, case-cohort study included patients over 18 years of age admitted to Duke University Hospital between Jun 1, 2013 and Jun 1, 2017 with a blood culture positive for Candida spp. Treatment-, patient-, and disease-specific data were collected, and outcome (success/failure) determined 90 days after the index culture. An odds ratio (OR) and 95% confidence interval (95%CI) were calculated for the following during therapy: receipt of RRT, fluconazole monotherapy regimen, intensive care unit (ICU) stay, and neutropenia.

Results:

Among the 112 encounters (from 110 unique patients) included, treatment failure occurred in 8/112 (7.1%). Demographics were comparable between outcome groups. Among 12 patients receiving concomitant RRT, only 1 patient failed therapy. With regard to treatment failure, no significant differences were observed with RRT (OR, 1.21; 95%CI, 0.14 – 10.75), fluconazole monotherapy regimen (OR, 1.59; 95%CI, 0.3-8.27), ICU stay (OR, 1.43; 95%CI, 0.32-6.29), and neutropenia (0 treatment failures).

Conclusions:

Treatment failure, receipt of concomitant RRT, and neutropenia were infrequent in patients undergoing treatment for candidemia. In our cohort, exposure to RRT, a fluconazole monotherapy regimen, ICU stay, or neutropenia during treatment did not impact treatment outcome.

Enhanced Recovery after Surgery (ERAS) Protocols Expanded over Multiple Service Lines Improves Patient Care and Hospital Cost

Enhanced recovery after surgery (ERAS) may improve patients' postoperative course. Our center implemented the ERAS protocol for the colorectal service in 2016, and then expanded to multiple service lines over the course of 1.5 years. Our aim was to determine whether broad implementation of ERAS protocols across different service lines could improve patient care. All ERAS patients from 2018 were captured prospectively. For each service line using ERAS, one full year of data preceding ERAS was compared. ERAS service lines included colorectal, gynecology laparoscopic, gynecology open, hepatopancreaticobiliary, urology - nephrectomy and cystectomy, spinal fusion, cardiac surgery-coronary artery bypass grafting. ERAS and pre-ERAS services were compared based on length of stay (LOS), complications, readmission, and mortality rates. In addition, hospital costs were collected during this time frame. ERAS protocols significantly decreased LOS for colorectal, gynecology, and spine. Complications were significantly decreased in colorectal, gynecology, urology, and spine. Readmissions did not significantly increase in any service line except spine. There was no significant change in mortality. ERAS proved to save the hospital 1847 days and cost saving of almost $5 million in 2018. Implementing ERAS broadly improved patient outcomes (LOS, complications, readmission, and mortality) while providing cost savings to the hospital.

A-29 The Mediating Effects of Personality on Sleep Quality and Executive Dysfunction

Objective

This study examined the relationship between personality traits, sleep quality, and executive dysfunction.

Method

Participants were 195 college students (65.6% female; 53.8% Caucasian, 33.3% African American, 4.1% Asian,; age range 17 – 46 years, Mage = 19.58 years, SD = 3.41; 73.3% no psychological diagnosis) who completed the following attention tasks: 120-item IPIP Neo (NEO), the Pittsburgh Sleep Quality Index (PSQI), and the Barkley Deficits in Executive Functioning Rating Scale-IV (BDEFS-IV).

Results

Mediation analyses were tested using 5000 bootstrapping resamples with bias-corrected 95% confidence estimates to investigate if personality traits mediated the effect of sleep quality on executive dysfunction. The total effect between PSQI and BDEFS-IV was significant, F(1,193) = 15.80, p < .001, r2 = .08, 95% CI = 1.79, 5.31). The model was significant when examining the relationship between the independent variable, mediators, and dependent variable, F(6,188) = 29.31, p < .000, r2 = .48. Three of the five mediators demonstrated significant indirect effects: neuroticism, (B = 1.07, t (188) = 5.39, p = .000, 95% CI = .68, 1.46), extraversion (B = .63, t (188) = 3.46, p = .000, 95% CI = .27, .99), and conscientiousness (B = -1.91, t (188) = -7.46, p = .000, 95% CI = -2.42, -1.41). The direct effect of PSQI and BDEFS-IV was not significant (B = .731, t (188) = .99, p = .32, 95% CI = -.72, 2.18) when controlling for all five mediators, confirming a full mediation.

Conclusions

Neuroticism, Extraversion, and Conscientiousness significantly mediated the relationship between self-reported sleep quality and executive dysfunction.

A-64 The Relationship between Big-5 Personality Factors and Cognitive Health

Objective

The purpose of the current study was to examine the relationship between factors of personality and cognitive health.

Methods

Two hundred and two participants (M age = 19.51, SD = 3.33; M education = 12.40, SD = .75; 72.3% Female, 55.3% White, 36.0% African American, 4.6% Asian, 4.1% Other) completed the cognitive health questionnaire (CHQ) and a 120-item International Personality Item Pool Representation of the NEO-PI-R (IPIP-NEO) as a part of a larger battery in an institutional setting. A CHQ total score was calculated based on items of four positive factors of cognitive health including social/intellectual activities, nutrition, exercise, and eating habits.

Results

A multiple linear regression using backwards elimination was calculated to predict scores on the Cognitive Health Questionnaire utilizing the five personality factors of the IPIP-NEO. The overall five-factor regression model yielded a significant regression equation (F(5,196) = 7.76, p < .001), with an R2 of .165. The final three-factor regression model consisting of extraversion, openness, and consciousness yielded significant results (F(3,198) = 12.70, p < .001), with an R2 of .161.

Conclusions

This exploratory study investigated the relationship between factors of personality and cognitive health. Although a multiple regression model involving all five factors of personality were significantly predictive of cognitive health, the results of this study indicate that greater variance of cognitive health is predicted by extraversion, openness and conscientiousness than neuroticism and agreeableness. Further research should investigate each factor of cognitive health and how these components are predicted by features of personality.

373. Impact of Concurrent Renal Replacement Therapy on Treatment Outcomes of Candidemia in Adults

Background

Treatment of candidemia is complex. Studies examining relationships between patient-related factors and treatment outcome are limited, often based on all-cause mortality. Our objectives were to compare concurrent prespecified factors between patients with and without treatment failure among adults with candidemia.

Methods

This IRB-approved, single-center, case-cohort study included patients >18 years old admitted to Duke University Hospital between June 1, 2013 and June 1, 2017 with a blood culture positive for Candida spp. Treatment-, patient-, and disease-specific data were collected, and outcome (success/failure) determined 90 days after the index culture. An odds ratio (OR) and 95% confidence interval (95% CI) were determined for receipt of renal replacement therapy (RRT), fluconazole-containing regimen, ICU stay, and neutropenia between outcome groups.

Results

Among the 112 encounters (from 110 unique patients) included, treatment success was observed in 104/112 (92.9%). Demographics were comparable between treatment success and treatment failure groups. Among patients receiving concomitant RRT, 11/12 encounters (91.7%) were successfully treated. No significant differences were observed with regards to treatment failure with a fluconazole-containing regimen (OR, 1.59; 95% CI, 0.3–8.27), ICU stay (OR, 1.43; 95% CI, 0.32–6.29), and neutropenia (OR incomputable due to 0 treatment failures).

Conclusion

Treatment success occurred in 91.7% of adult patients receiving concomitant RRT while undergoing treatment for candidemia. Treatment with a fluconazole-containing regimen, RRT, ICU stay, and neutropenia did not differ between the treatment outcome groups.

Disclosures

All authors: No reported disclosures.

Observation of an Unusual Upward-Going Cosmic-Ray-like Event in the Third Flight of ANITA

We report on an upward traveling, radio-detected cosmic-ray-like impulsive event with characteristics closely matching an extensive air shower. This event, observed in the third flight of the Antarctic Impulsive Transient Antenna (ANITA), a NASA-sponsored long-duration balloon payload, is consistent with a similar event reported in a previous flight. These events could be produced by the atmospheric decay of an upward-propagating τ lepton produced by a ν_{τ} interaction, although their relatively steep arrival angles create tension with the standard model neutrino cross section. Each of the two events have a posteriori background estimates of ≲10^{-2} events. If these are generated by τ-lepton decay, then either the charged-current ν_{τ} cross section is suppressed at EeV energies, or the events arise at moments when the peak flux of a transient neutrino source was much larger than the typical expected cosmogenic background neutrinos.

Embedded Game Design as a Method for Addressing Social Determinants of Health

This paper, describes the design, development, and evaluation of The Test, a theory-based mobile game prototype designed to promote HIV testing by providing information and influencing motivations, and behavioral intentions among YMSM. The Test was designed using embedded design, first described by Kaufman & Flanagan (2015), which diverges from traditional "educational game" design strategies by mixing on-message content with nonfocal content, in an attempt to make the overall experience more approachable and engaging. One challenge of embedded design is that it targets attitudes and actions that are not always proximate to a particular behavior. Games with embedded content forgo explicit takeaways, and their possible distal effects present a challenge to traditional tests of efficacy. The benefit of embedded design, however, is that its holistic or ecological design approach (which considers feelings, emotions, affects, social relations, and connections to broader communities) stands in close alignment with the social-ecological model.

Systematic review and meta-analysis of the impact of preconception lifestyle interventions on fertility, obstetric, fetal, anthropometric and metabolic outcomes in men and women

STUDY QUESTION

What is the impact of preconception lifestyle interventions on live birth, birth weight and pregnancy rate?

SUMMARY ANSWER

Lifestyle interventions showed benefits for weight loss and increased natural pregnancy rate, but not for live birth or birth weight.

WHAT IS KNOWN ALREADY

Evidence on the practice and content of preconception counseling and interventions is variable and limited.

STUDY DESIGN, SIZE, DURATION

Systematic review and meta-analysis (MA). Main search terms were those related to preconception lifestyle. Database searched were Ovid MEDLINE(R), EBM Reviews, PsycINFO, EMBASE and CINAHL Plus. No language restriction was placed on the published articles. The final search was performed on 10 January 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were non-pregnant women of childbearing age intent on conceiving or their male partners. Exclusion criteria include participants with BMI < 18 kg/m2, animal trials, hereditary disorder in one or both partners and trials focusing solely on alcohol or smoking cessation/reduction, micronutrient supplementation, or diabetes control. Anthropometric, fertility, obstetric and fetal outcomes were assessed. Bias and quality assessments were performed.

MAIN RESULTS AND THE ROLE OF CHANCE

The search returned 1802 articles and eight studies were included for analysis. Populations targeted were primarily overweight or obese subfertile women seeking reproductive assistance, with few community-based studies and none including men. MA showed greater reduction in weight (n = 3, P < 0.00001, mean difference: -3.48 kg, 95% CI: -4.29, -2.67, I2 = 0%) and BMI (n = 2, P < 0.00001, mean difference: -1.40 kg/m2, 95% CI: -1.95, -0.84, I2 = 24%) with intervention. The only significant fertility outcome was an increased natural pregnancy rate (n = 2, P = 0.003, odds ratio: 1.87, CI: 1.24, 2.81, I2 = 0%). No differences were observed for ART adverse events, clinical pregnancy, pregnancy complications, delivery complications, live birth, premature birth, birth weight, neonatal mortality or anxiety. Risk of bias were high for three studies, moderate for three studies and low for two studies, Attrition bias was moderate or high in majority of studies.

LIMITATIONS, REASONS FOR CAUTION

Results were limited to subfertile or infertile women who were overweight or obese undergoing ART with no studies in men. The heterogeneous nature of the interventions in terms of duration and regimen means no conclusions could be made regarding the method or components of optimal lifestyle intervention. Attrition bias itself is an important factor that could affect efficacy of interventions.

WIDER IMPLICATIONS OF THE FINDINGS

Existing preconception lifestyle interventions primarily targeted overweight and obese subfertile women undergoing ART with a focus on weight loss. It is important to note that natural conception increased with lifestyle intervention. This emphasizes the need for further research exploring optimal components of preconception lifestyle interventions in the broader population and on the optimal nature, intensity and timing of interventions.

STUDY FUNDING/COMPETING INTEREST(S)

No conflict of interest declared. C.L.H. is a National Heart Foundation Postdoctoral Research Fellow. B.H. is funded by an Alfred Deakin Postdoctoral Research Fellowship. H.J.T. and B.W.M. hold NHMRC Practitioner fellowships. L.J.M. is supported by a SACVRDP Fellowship; a program collaboratively funded by the NHF, the South Australian Department of Health and the South Australian Health and Medical Research Institute.

PROSPERO REGISTRATION NUMBER

CRD42015023952.

A comparison of HIV-risk behaviors between young black cisgender men who have sex with men and young black transgender women who have sex with men

This study compared sexually transmitted infection (STI)-associated risks between young Black cisgender men who have sex with men (YBMSM) and young Black transwomen who have sex with men (YBTWSM). Comparisons pertained to: (1) prevalence of infections; (2) sexual risk; (3) partner-related risks; and (4) socioeconomic marginalization. YBMSM (n = 577) and YBTWSM (n = 32) were recruited from an STI clinic in the USA. Volunteers completed a computer-assisted self-interview and medical records were abstracted for STI/HIV information. Significantly greater prevalence of pharyngeal Chlamydia ( P < .001) and pharyngeal gonorrhea ( P = .04) occurred among YBTWSM; however, both associations were moderated and only significant for HIV-uninfected volunteers. YBTWSM had more oral sex partners and more frequent engagement in oral sex. The number of new sex partners for anal receptive sex was greater in YBTWSM. YBTWSM were more likely to exchange sex for money/drugs ( P < .001), have sex with men recently in prison ( P < .001), who were "anonymous" ( P = .004), or who were "one night stands" ( P < .001). YBTWSM were more likely to depend on sex partners for money food, etc. ( P < .001), to miss meals due to lack of money ( P = .01), and to report having ever being incarcerated ( P = .009). Compared to cisgender YBMSM, YBTWSM experience multiple risk factors relative to the acquisition/transmission of STIs and HIV.

Assessment of a Modified Antibiotic Prophylaxis Open Fracture Protocol

Background

National guidelines support antibiotic prophylaxis for open fracture with cefazolin +/− aminoglycoside based on fracture grade and contamination. The purpose of this study was to assess a modified adult antibiotic prophylaxis open fracture protocol (AOFP) which recommended weight-based cefazolin for low-grade fractures or ciprofloxacin plus vancomycin for high-grade fractures.

Methods

Adult patients with open fractures admitted to Palmetto Health Richland between January 2012 and December 2016 were screened for study inclusion. Exclusion criteria were receipt of antibiotics for reasons other than open fracture, death prior to wound closure, and local admission time &gt;48 hours after time of injury. Compliance to all elements of AOFP was assessed. Clinical endpoints including open fracture infection rates, epidemiology, and drug-related adverse events were compared between pre-implementation (January 2012 – December 2012) and post-implementation period (November 2015 – December 2016). χ 2 and t-tests as appropriate were used to compare outcomes between groups.

Results

Following exclusions 189 patients were included in the analysis (90 pre- vs. 99 post-AOFP, respectively). Post-AOFP, a 17% (16/93) adherence rate to all AOFP elements was found. Appropriate agents were selected in 82.8% (77/93). The most common reasons for non-adherence were incorrect dosing and prolonged antibiotic duration. Fracture site infection rates were 23.3% (21/90) and 7.1% (7/99) in pre- and post-AOFP groups, respectively (P = 0.001). Infections primary caused by Gram-negative pathogens in pre-AOFP and Gram-negative organisms comprised 62 and 40% of open fracture site infections in pre- and post-AOFP groups, respectively. Incidence of acute kidney injury, Clostridium difficile-associated diarrhea, and other antibiotic-associated AEs were rare and comparable between groups. Change in median days to infection (55.6 days vs. 56.55 days, P = 0.71) and median duration of antibiotics in hours (48.0 vs. 54.7, P = 0.59) was not significantly different post implementation.

Conclusion

Local adherence to all elements of the modified AOFP was low, yet the appropriate agent(s) was used in majority of cases. The modified AOFP was associated with a numerical decrease in infection rates post-open fracture and comparable AEs.

Disclosures

P. B. Bookstaver, Rock Pointe: Content Developer, Consulting fee