bluuebunny/crossref_metadata_2025 huggingface dataset:
Inferior Vena Cava Thrombosis, Appendicitis Mimic
Authors: Kaylor Ryan M , Gehrz Joseph A , Gutweiler Alex A , Cortes James S
Published: December 2021

Right lower quadrant abdominal pain is a common presentation to the Emergency Department. While appendicitis is a frequently diagnosed pathology associated with this complaint, there are multiple, well-documented alternatives that must be considered. The authors present a unique case of a 20 year old active duty male who presented with 3 days of acutely worsening right lower quadrant abdominal pain, right flank pain, and anorexia. Following a detailed work-up, computed tomography and magnetic resonance imaging (MRI) demonstrated a bland thrombus within the inferior vena cava (IVC) secondary to a vascular web. This case highlights the difficulty in astutely diagnosing appendicitis utilizing clinical examination and scoring metrics. While IVC thrombosis is a rare phenomenon, it should be considered in the emergency physician’s differential for right lower quadrant abdominal pain, particularly when additional nonspecific symptoms are present.
Increased replication stress and R-loop accumulation in EGFRvIII-expressing glioblastoma present new therapeutic opportunities
Authors: Struve Nina , Hoffer Konstantin , Weik Anna-Sophie , Riepen Britta , Krug Leonie , Cetin Meryem H , Burmester Jasmin , Ott Leonie , Liebing Jana , Gatzemeier Fruzsina , Müller-Goebel Justus , Gerbach Mirja , Bußmann Lara , Parplys Ann Christin , Unger Kristian , Mansour Wael Y , Schüller Ulrich , Rieckmann Thorsten , Petersen Cordula , Rothkamm Kai , Short Susan C , Kriegs Malte
Published: December 2021

Background

The oncogene epidermal growth factor receptor variant III (EGFRvIII) is expressed in approximately one-third of all glioblastomas (GBMs). So far it is not clear if EGFRvIII expression induces replication stress in GBM cells, which might serve as a therapeutical target.

Methods

Isogenetic EGFRvIII− and EGFRvIII+ cell lines with endogenous EGFRvIII expression were used. Markers of oncogenic and replication stress such as γH2AX, RPA, 53BP1, ATR, and CHK1 were analyzed using western blot, immunofluorescence, and flow cytometry. The DNA fiber assay was performed to analyze replication, transcription was measured by incorporation of EU, and genomic instability was investigated by micronuclei and CGH-Array analysis. Immunohistochemistry staining was used to detect replication stress markers and R-loops in human GBM samples.

Results

EGFRvIII+ cells exhibit an activated replication stress response, increased spontaneous DNA damage, elevated levels of single-stranded DNA, and reduced DNA replication velocity, which are all indicative characteristics of replication stress. Furthermore, we show here that EGFRvIII expression is linked to increased genomic instability. EGFRvIII-expressing cells display elevated RNA synthesis and R-loop formation, which could also be confirmed in EGFRvIII-positive GBM patient samples. Targeting replication stress by irinotecan resulted in increased sensitivity of EGFRvIII+ cells.

Conclusion

This study demonstrates that EGFRvIII expression is associated with increased replication stress, R-loop accumulation, and genomic instability. This might contribute to intratumoral heterogeneity but may also be exploited for individualized therapy approaches.
2. Space Time Trends of Community Onset Staphylococcus aureus Infections in Children Living in Southeastern United States: 2002-2016
Authors: Immergluck Lilly , geng Ruijin , Li Chaohua , Edelson Mike , Waller Lance , Rust George , Xu Junjun , Ali Fatima , Baltrus Peter , Leong Traci
Published: December 2021

Background

Staphylococcus aureus (S. aureus) remains a serious cause of infections in the United States and worldwide. Methicillin susceptible S. aureus (MSSA) is the cause of half of all health care–associated staphylococcal infections, and Methicillin Resistant S. aureus (MRSA) is the leading cause of community onset skin and soft tissue infections in the US. This study looks at a 15-year trend of community onset (CO)-MRSA and MSSA infections and determines ‘best’ to ‘worst’ infection trends. We identified distinct groups of CO-MRSA and MSSA infection rate trajectories by grouping census tracts of the 20 county Atlanta Metropolitan Statistical Area (MSA) between 2002 to 2016 with similar temporal trajectories.

Methods

This is a retrospective study from 2002-2016, using electronic health records of children living in Atlanta, Georgia with S. aureus infections and relevant US census data (at the census tract level). A group based trajectory model was applied to generate community onset S. aureus trajectory infection groups (low, high, very high) by census tract and were mapped using ArcGIS.

Results

Three CO-MSSA infection groups (low, high, very high) and two CO-MRSA infection groups (low, high) were detected among 909 census tracts in the 20 counties. We found ~74% of all the census tracts with S.aureus occurrence during this time period belonged to low infection rate groups for both MRSA and MSSA, with a higher proportion occurring in the less densely populated counties. Census tracts in DeKalb County, one of Atlanta’s most densely populated areas, had the highest proportion of the worst infection trend patterns (CO-MRSA high or very high, CO-MSSA high or very high).

Trends of Community-Onset MRSA and MSSA Infection Rates Based on Group-based Trajectory Models

Spatial patterns for CO-MRSA and CO-MSSA Trajectory Trends in the Atlanta Metropolitan Area Between 2002 to 2016

Conclusion

Trends of S. aureus infection patterns, stratified by antibiotic resistance over geographic areas and time, identify communities with higher risks for MRSA infection compared to MSSA infection. Further investigation of the determinants of the trajectory groupings and the geographic outliers identified by this study may be a way to target prevention strategies aimed to prevent S. aureus infections.

Disclosures

All Authors: No reported disclosures
50. Pilot Study on Offering HIV Pre-Exposure Prophylaxis (PrEP) to People Who Inject Drugs (PWID) in the Inpatient Setting
Authors: Marryshow Terry A , Caro Jose
Published: December 2021

Background

Due to the ongoing opioid epidemic, PWID represent an increasingly high-risk population for HIV infections in the United States, accounting for 10% of all new HIV diagnoses in 2018 and 12.5% of all deaths among people living with HIV. PrEP is an effective means of preventing HIV, though uptake has been low among PWID, possibly due to low access to care. Inpatient admissions may represent missed opportunities for provision of PrEP to PWID.

Methods

Inpatient prescriptions for tenofovir disoproxil fumarate-emtricitabine (TDF-FTC) from 10/2019 to 8/2020 were analyzed to assess baseline provision of PrEP to PWID. Physicians on the Infectious Diseases ward service were anonymously queried on perceived barriers and their practices regarding provision of PrEP to PWID. PWID admitted from 9/2020 to 5/2021 were approached at bedside, provided counseling on PrEP and offered initiation prior to discharge. We analyzed patient perceptions and acceptance of PrEP.

Results

16 total prescriptions for TDF-FTC were provided at discharge from 10/2019 to 8/2020, with 0 being for PrEP in PWID. The 8 physicians surveyed estimated caring for an average 4 PWID per week of service. 5/8 physicians reported that at least one PWID was offered PrEP during their most recent week of service. The most commonly reported physician barrier to prescribing PrEP was uncertainty regarding adherence and follow up (5/8). 30 patients were approached, with 14 reporting prior knowledge of PrEP. 18 were willing to engage in further education. Only 4 were accepting of PrEP, with 2 provided prescriptions. Of those declining, 13 denied equipment sharing, 4 denied active drug use, 7 stated a commitment to future abstinence, 3 were unwilling to adhere to a daily medication, 2 declined due to concerns of adverse effects and 1 due to concerns regarding stigma.

Table 1. Physician Reported Barriers to Prescribing PrEP (n = 8)

Table 2. Patient Knowledge and Acceptance of PrEP (n = 30)

Table 3. Patient Reasons for Declining PrEP (n = 30)

Conclusion

In this pilot study, few admitted PWID were accepting of PrEP. Attempts to initiate PrEP in PWID in the inpatient setting may not be effective at our institution. The most common reason for declining was low self-perceived risk of HIV acquisition; however, a significant proportion of patients showed interest in further education. Therefore, the inpatient setting may be a valuable site of initial counseling and referral for future potential provision of PrEP in the outpatient setting.

Disclosures

All Authors: No reported disclosures
60. Creation and Comparison of a Machine Learning Decision Tree and Traditional Risk Score to Predict Ceftriaxone Resistance in Cancer Patients with E. coli Bacteremia
Authors: Moc Courtney , Shropshire William , McDaneld Patrick , Shelburne Samuel A , Aitken Samuel L , Aitken Samuel L
Published: December 2021

Background

There are several clinical tools that have been developed to predict the likelihood of extended-spectrum β-lactamase producing Enterobacterales; however, the creation of these tools included few patients with cancer or otherwise immunosuppressed. The objectives of this retrospective cohort study were to develop a decision tree and traditional risk score to predict ceftriaxone resistance in cancer patients with Escherichia coli (E. coli) bacteremia as well as to compare the predictive accuracy between the tools.

Methods

Adults age ≥ 18 years old with E. coli bacteremia at The University of Texas MD Anderson Cancer Center from 1/2018 to 12/2019 were included. Isolates recovered within 1 week from the same patient were excluded. The decision tree was constructed using classification and regression tree analysis, with a minimum node size of 10. The risk score was created using a multivariable logistic regression model derived by using stepwise variable selection with backward elimination at level 0.2. The decision tree and risk score statistical metrics were compared.

Results

A total of 629 E. coli isolates were screened, of which 580 isolates met criteria. Ceftriaxone-resistant (CRO-R) E. coli accounted for 36% of isolates. The machine learning-derived decision tree included 5 predictors whereas the logistic regression-derived risk score included 7 predictors. The risk score cutoff point of ≥ 5 points demonstrated the most optimized overall classification accuracy. The positive predictive value of the decision tree was higher than that of the risk score (88% vs 74%, respectively), but the area under the receiver operating characteristic curve and model accuracy of the risk score was higher than that of the decision tree (0.85 vs 0.73 and 82% vs 74%, respectively).

Figure 1. Clinical Decision Tree

Table 1. Regression Model and Assigned Points for Clinical Risk Score

Table 2. Statistical Metrics of Clinical Decision Tree and Clinical Risk Score

Conclusion

The decision tree and risk score can be used to determine the likelihood of whether a cancer patient with E. coli bacteremia has a CRO-R infection. In both clinical tools, the strongest predictor was a history of CRO-R E. coli colonization or infection in the last 6 months. The decision tree was more user-friendly, has fewer variables, and has a better positive predictive value in comparison to the risk score. However, the risk score has a significantly better discrimination and model accuracy than that of the decision tree.

Disclosures

Samuel L. Aitken, PharmD, MPH, BCIDP, Melinta Therapeutoics (Individual(s) Involved: Self): Consultant, Grant/Research Support
63. PK-RNN-V: A Deep Learning Model for Vancomycin Therapeutic Drug Monitoring using Electronic Health Record Data
Authors: Masayuki Nigo , Tran Hong Thoai Nga , Xie Ziqian , Feng Han , Bekhet Laila , Hongyu Miao , Zhi Degui
Published: December 2021

Background

Therapeutic drug monitoring (TDM) for vancomycin (VAN) with Bayesian models is recommended by national guidelines. However, limited data incorporating the models may hurt the performance. Our aim is to develop a novel deep learning-based pharmacokinetic model for vancomycin (PK-RNN-V) using electronic medical records (EHRs) data to achieve more accurate and personalized predictions for VAN levels.

Methods

EHR data were retrospectively retrieved from Memorial Hermann Hospital System, comprising 14 hospitals in the greater Houston area. All patients who received VAN and had any VAN levels were eligible. Patients receiving hemodialysis and extracorporeal membrane oxygenation were excluded. Demographic data, vital signs, diagnostic codes, concomitant medications, VAN administration, and laboratory data were preprocessed as longitudinal data. VAN infusion, VAN level measurement, or each hospital day were the time steps for the models. The dataset was splited 70:15:15 for training, validation, and test sets. Our PK-RNN-V model predicted individual patient volume distribution (v) and VAN elimination (k) at each time step using an irregular timesteps GRU model. To compare, Bayesian models were developed from publicly available models, and tuned to feedback the first VAN level to update the v and k. (VTDM)

Results

A total of 12,258 patients with 195,140 encounters were identified from Aug, 2019 and March, 2020. After exclusion of 6,775 patients, 5,483 patients with 8,689 encounters were included. Table 1 summarized the characteristics of patients included in our study. 55,336 doses of VAN were administered with a median dosage of 1.0 gm. VAN levels were measured 18,588 times at various timings. The median VAN level was 14.7 mcg/mL Table 2 described the performance of our models and VTDM models. Our model exhibited better performance compared to VTDM model (RMSE: 5.64 vs. 6.57, respectively). Figure 1 shows example prediction curves of VAN levels from each model.

Conclusion

PK-RNN-V model is a novel approach to predict patient PK and VAN levels. Our results revealed promising performance of this model. Our model can take a wide range of real-world patient data into the model. Further studies are warranted for external validations and model optimizations.

Disclosures

All Authors: No reported disclosures
90. Impact of Infection Control Assessment and Response (ICAR) Visit on Candida auris Colonization Rates at Seven Long Term Acute Care Hospitals (LTACH) in Los Angeles County
Authors: Bhurtyal Kiran , Nguyen Jennifer , Clarke Anthony , OYong Kelsey , Bhaurla Sandeep , Takiguchi Eric , Baldwin Leslie , Rubin Zachary
Published: December 2021

Background

Public health authorities often use Infection Control Assessment and Response (ICAR) visits during Candida auris (C. auris) outbreak investigation to identify facility-level infection prevention and control (IPC) practice gaps and make recommendations to address those gaps. As an adjunct to ICAR visit, point prevalence surveys (PPS) provide an objective measure to determine if IPC recommendations are implemented. Because they require significant public health resources to perform, we evaluated the impact of ICAR visits on C. auris colonization rates.

Methods

PPS were conducted at seven long-term acute-care hospitals (LTACH) with C. auris outbreaks in Los Angeles County from July 2020 to May 2021. Skin swabs collected at PPS were tested for C. auris colonization by PCR technique. Pre-ICAR PPS results were compared with the average of two serial post-ICAR PPS results using repeated measures ANOVA test. Linear regression was used to estimate associations between individual ICAR domains and C. auris colonization.

Results

54 PPS were conducted at seven LTACHs with at least one ICAR visit made for every two PPS. On average, PPS were conducted 14 days (range 1-15 days) before and 10 days (range 4-33 days) after an ICAR visit. PPS positive rates with ICAR visit dates for each LTACH are shown in figure 1. Overall, ICAR visits were associated with a significant decrease (p=0.035) in the average of the positive rates in two serial post-ICAR PPS. When individual domain (hand hygiene, contact precautions, and environmental disinfection) of ICAR tool was analyzed, only adherence to environmental disinfection was significantly associated (p=0.038) with decrease in C. auris colonization rates. There was a moderate negative correlation (R2 = 0.26, β= -0.33) between environmental disinfection adherence and the magnitude of decrease in the colonization rates across all LTACHs (Figure 2).

Figure 1

Figure 2

Conclusion

ICAR visits were found to be significantly associated with a decrease in the average PPS positive rate on serial PPS. Parts of the ICAR tool that assessed environmental disinfection at the facility seemed most correlated with decrease in C. auris colonization rate. Streamlining the ICAR process to focus on the most impactful parts of ICAR tool may be a more efficient intervention to control C. auris outbreaks.

Disclosures

All Authors: No reported disclosures
817. Appropriate Sites for the Active Surveillance of Carbapenemase-producing Enterobacteriaceae
Authors: Park Joung Ha , Choi Hye-Suk , Yang Hyejin , Lee Hyun-Ju , Kwak Sun Hee , Kim Eun Ok , Chong Yong Pil , Choi Sang-Ho , Lee Sang-Oh , Kim Yang Soo , Sung Heungsup , Kim Mi-Na , Kim Sung-Han , Jung Jiwon
Published: December 2021

Background

Active surveillance tests for carbapenemase-producing Enterobacteriaceae (CPE) are recommended in patients showing risk factors for colonization by these bacteria. There are limited data however on whether surveillance tests for anatomic sites other than the stool would be useful to detect CPE colonization, and we investigated this in our present study.

Methods

Retrospective analysis was performed on cases at our tertiary care hospital during a 5-year period. The study patients with CPE colonization had been admitted to our surgical intensive care unit (SICU) or sub-ICU for liver transplantation in this period and undergone surveillance tests for both the stool and other sites. Patients were grouped as stool CPE negative (but which included CPE positive cases from initial sputum and other site tests) or positive.

Results

Among the total study cohort of 158 patients, 138 (87.3%) were included in the stool CPE positive group and the remaining 20 (12.7%) in the stool CPE negative group. While the sensitivity of CPE surveillance testing of the stool was 87.3% (95% CI 81.1-92.1), the sensitivity when combining stool and sputum samples was 93.7% (88.7-96.9). The transmission rates were similar for patients showing CPE positivity in the stool, sputum and other sites, at 4.8% (27/557), 4.7% (3/64), and 6.7% (1/15), respectively (p = 0.95).

Conclusion

The sensitivity of CPE detection in a stool sample is suboptimal for ruling out CPE colonization and the transmission rates are similar between stool-positive or -negative cases. Combining surveillance of the stool with other sites may be needed for detecting CPE.

Disclosures

All Authors: No reported disclosures
824. Analysis of Comorbidities and Use of Co-medications in 28,089 HIV-positive Patients: A Nationwide Cohort Study From 2009 to 2019 in Japan
Authors: Naito Toshio , Suzuki Mai , Fukushima Shinichi , Yuda Mayumi , Fukui Nobuyuki , Tsukamoto Shotaro , Fujibayashi Kazutoshi , Goto-Hirano Keiko , Kuwatsuru Ryohei
Published: December 2021

Background

Comorbidities are associated with a high burden of disease in human immunodeficiency virus (HIV)- positive patients. The objective was to investigate the prevalence of chronic comorbidities and the use of co-medications in HIV-positive patients in Japan.

Methods

This longitudinal cohort study retrospectively analyzed clinical information from HIV-positive patients using antiretroviral therapy (ART) between April 2009 and April 2019. Demographic characteristics, numbers and types of chronic comorbidities and numbers and types of co-medications, were described by age groups. This is the first report to analyze comorbidities and the polypharmacy of all patients in the cross-sectional National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB), which contains data on the largest number of HIV-positive patients in Japan, available to date.

Results

Overall, 28,089 HIV-positive patients (male 91·9%) who used ART were identified. About 40% of 28,089 patients had at least one chronic comorbidity. The number of acquired immunodeficiency syndrome (AIDS)-defining cancers and non-AIDS-defining cancers in this Japanese cohort was 2,432 (8·7%) and 2,485 (8·8%), respectively. The incidence of AIDS-defining cancers was 6·4% for non-Hodgkin lymphoma and 2·5% for Kaposi’s sarcoma, with bronchus or lung cancer being the most common of the non-AIDS-defining cancers. Syphilis was the most common infection (47·2%). The cumulative burden of vascular disease and AIDS-free cancer increased with age. The most common therapeutic categories of co-medications were systemic antibacterials (42%) and antacids, antiflatulents and antiulcerants (38·8%). Most of the patients used at least one co-medication (71·4%), and the numbers of co-medications used were greater in the older age groups.

Conclusion

The burden of chronic comorbidities and co-medication were found to be greater in older than younger patients, among 28,089 HIV-positive patients in a nationwide study in Japan. This finding suggests the need to identify elderly persons living with HIV and to appropriately manage their HIV and comorbidities.

Disclosures

All Authors: No reported disclosures
843. Targeted HIV Testing for Patients Hospitalized for COVID-19
Authors: Virata Michael D , Villanueva Merceditas , Miceli Janet
Published: December 2021

Background

SARS-CoV-2 causes a severe respiratory illness known as COVID-19. Treatment options in the early portion of the COVID-19 pandemic included the use of antiretroviral agents i.e. protease inhibitors (PIs) such as lopinavir (LPV) that had been shown to have activity against the main proteases of SARS-CoV-2 in vitro but with very limited clinical data. Prior to the use of PIs, HIV testing would be indicated to ensure that patients who were not previously diagnosed with HIV would start appropriate HIV treatment. In this unique situation, HIV testing would be utilized not based on traditional HIV risk factors.

Methods

We performed a retrospective search from a specific systems database of patients admitted to Yale-New Haven Health System (YNHHS) with a diagnosis of COVID-19 infection. We identified a subset of patients who were HIV tested. Most were done prior to initiating PI treatment. Demographics, comorbidity scores and specific underlying conditions were also tabulated. We performed Kruskal Wallis and Chi-Squared analysis to test for significance between HIV- and HIV+ patients.

Results

The total no. of patients admitted to the YNHHS with COVID-19 infection between the period from January 6, 2020 to January 6, 2021 was 5776. A cohort 964 (16.7%) patients were screened for HIV. Much of the testing occurred in the early COVID periods (Figure 1) when PIs were considered as part of the treatment algorithm. Sixty-seven (0.07%) patients tested HIV+ with 3 (0.003%) being newly diagnosed (Fig 2). Compared to HIV- patients, HIV+ were more likely to be identified as Black, with higher mean Elixhauser Comorbidity scores and significant associations with conditions such as hypertension, pulmonary disease, complicated diabetes, liver disease, renal failure and depression (Table 1). These co-morbidities have been correlated with higher risk of hospitalization for people living with HIV (PWH).

Figure 2. COVID Admission and HIV Status

The graph represents HIV testing results over the entire study period.

Table 1. Demographics and Comorbidites

Represents demographics and comorbidities of HIV- & HIV+ patients

Figure 1. COVID Admissions and HIV Testing

COVID admissions over time and the performance of HIV testing

Conclusion

This is one of the first reports on targeted HIV testing for patients not using identifiable traditional HIV risk factors who were admitted to a large healthcare system for COVID19 infections. The percentage of newly HIV diagnosed patients from this cohort was considered to be < known HIV infection rates for our population. The majority of PWH were already established in care prior to their COVID19 diagnosis.

Disclosures

All Authors: No reported disclosures
845. Impact of the COVID-19 Pandemic on Routine HIV Screening in an Emergency Department
Authors: Aguilera Elizabeth A , Rodriguez Gilhen , Del Bianco Gabriela P , Heresi Gloria , Murphy James , Prater Samuel
Published: December 2021

Background

The Emergency Department (ED) at Memorial Hermann Hospital (MHH) - Texas Medical Center (TMC), Houston, Texas has a long established screening program targeted at detection of HIV infections. The impact of the COVID-19 pandemic on this screening program is unknown.

Methods

The Routine HIV screening program includes opt-out testing of all adults 18 years and older with Glasgow score > 9. HIV 4th generation Ag/Ab screening, with reflex to Gennius confirmatory tests are used. Pre-pandemic (March 2019 to February 2020) to Pandemic period (March 2020 to February 2021) intervals were compared.

Results

72,929 patients visited MHH_ED during the pre-pandemic period and 57,128 in the pandemic period, a 22% decline. The number of patients tested for HIV pre-pandemic was 9433 and 6718 pandemic, a 29% decline. When the pandemic year was parsed into first and last 6 months interval and compared to similar intervals in the year pre pandemic, 39% followed by 16% declines in HIV testing were found. In total, 354 patients were HIV positives, 209, (59%) in the pre-pandemic and 145 (41%) in the pandemic period.The reduction in new HIV infections found was directly proportional to the decline in patients visiting the MHH-ED where the percent of patients HIV positive was constant across intervals (2.21% vs 2.26%). Demographic and outcome characteristics were constant across the compared intervals.

Conclusion

The COVID -19 pandemic reduced detection of new HIV infections by screening in direct proportion to the reduction in MHH-ED patient visits. The impact of COVID-19 pandemic decreased with duration of the pandemic.

Disclosures

All Authors: No reported disclosures
850. Reasons for not Using PrEP and Actions that May Facilitate PrEP Uptake in Ontario and British Columbia, Canada
Authors: Espinosa Oscar Javier Pico , Hull Mark , Lachowsky Nathan , Hall David , Mohammed Saira , Fisher Karla , Grace Daniel , Gaspar Mark , Truong Robinson , Mitterni Leo , Harding Matthew , MacPherson Paul , Woodward Kevin , Rayek Simon , Peters Eric , Jollimore Jody , Kilduff Marshall , Maxwell John , Greene Warren , Durrant Garfield , Arkell Camille , Cordeiro Tyllin , Tan Darrell
Published: December 2021

Background

HIV Pre-exposure prophylaxis (PrEP) is an underutilized intervention to prevent HIV infection in Canada. Known barriers to PrEP uptake include lack of awareness, low HIV risk perception, side effects, PrEP not being publicly funded (which is the case in Ontario) and stigma. We aimed to identify barriers to PrEP use and actions that may facilitate PrEP uptake in Ontario and British Columbia.

Methods

Gay, bisexual and other men who have sex with men 19 years or older living in Ontario and British Columbia, Canada, answered a survey between July 2019 and August 2020. Participants who met Canadian PrEP guideline criteria for PrEP and not already using PrEP indicated which barriers were relevant to them and which actions would make them more likely to start PrEP. We used descriptive statistics and tested differences between Ontario and British Columbia using Chi-square tests for proportions and t-tests or Wilcoxon rank-sum tests for continuous variables.

Results

Of 1527 survey responses, 260 (184 in Ontario and 76 in British Columbia) who were never PrEP users and met criteria for PrEP were included. In Ontario, the most common barriers were affordability (43%) and concern about side effects (42%). In British Columbia, the most common reasons were concern about side effects (41%) and not feeling at high enough risk (36%). In Ontario, the actions that would most likely encourage the respondent to start PrEP were short waiting time (63%), the healthcare provider informing about their HIV risk being higher than perceived (62%) and a written step-by-step guide (60%). In British Columbia, the actions that would most likely encourage the respondent to start PrEP were short waiting time (68%), people speaking publicly about PrEP (68%) and their healthcare provider counselling about: their HIV risk being higher than perceived (64%), side effects of PrEP (64%) and about how PrEP works (62%).

Table. Top reasons for not using PrEP and top actions that might influence the decision to start PrEP stratified by province. (n= 184 in Ontario, n= 76 in British Columbia).

Conclusion

Concern about side effects and not feeling at high enough risk were common barriers. Short waiting times may increase PrEP uptake. In Ontario, the findings suggested lack of affordability. In British Columbia, actions involving healthcare providers were valued.

Disclosures

Kevin Woodward, MD FRCPC, Gilead (Independent Contractor) Darrell Tan, MD PhD, Abbvie (Grant/Research Support)Gilead (Grant/Research Support)GlaxoSmithKline (Scientific Research Study Investigator)ViiV Healthcare (Grant/Research Support)
857. Discussion and Initiation of HIV Pre-exposure Prophylaxis Were Rare Following Diagnoses of Sexually Transmitted Infections among Veterans
Authors: Kobayashi Takaaki , Van Epps Puja , Maier Marissa , Beste Lauren , Beck Brice , Alexander Bruce , Ohl Michael
Published: December 2021

Background

Healthcare encounters for the diagnosis and treatment of sexually transmitted infections (STIs) are common and represent a window of opportunity to discuss and initiate HIV pre-exposure prophylaxis (PrEP). Little is known about how frequently PrEP is discussed and initiated in association with encounters for STIs.

Methods

We conducted a retrospective cohort and nested case control study in the national Veterans Administration (VA) healthcare system to determine the frequency of PrEP discussion and initiation in association with clinical encounters for bacterial STIs (i.e. early syphilis, gonorrhea, and chlamydia). We used administrative data to identify patients with a first STI based on ICD 9 / 10 codes from January 2013–December 2018 , excluding patients with prior HIV diagnosis or PrEP use, or STI diagnosed in context of a visit to initiate PrEP (Figure 1). We used pharmacy data to determine the frequency of PrEP initiation within 90 days of the encounter for STI in this cohort. In the case control study, we matched 90 PrEP starters to 180 non-starters by day of STI diagnosis and reviewed chart notes from the STI diagnosis encounter to determine frequency of documentation of sexual history taking and PrEP discussions among subsequent PrEP initiators and non-initiators.

Results

We identified 23,312 patients with a first STI, of whom 90 (0.4%) started PrEP within 90 days. Adjusting for age, PrEP initiation was associated with urban residence (OR=5.0, 95Cl 1.8–13.4), White compared to Black race (OR=1.7, 95 Cl 1.1–2.8), and syphilis diagnosis (OR = 7.4, 95 Cl 4.7–11.6, table 1). Chart review revealed that discussion of PrEP was rare among people with STIs who did not subsequently start PrEP (1.1%, 95 CI 0.1–4.0, table 2). PrEP initiation was associated with documentation of any sexual history (80.0% of initiators vs. 51.0% of non-initiators, p < 0.01) and discussion of PrEP (52.2% vs. 1.1%, p < 0.01) during the initial STI diagnosis encounter.

Figure 1. Study flow chart

Table 1. Characteristics of patients with a first healthcare encounter with an STI diagnosis, by PrEP initiation within 90 days of encounter. N= 23,312

Table 2. Chart review findings from case control study. Ninety people who initiated PrEP (i.e., “cases”) were randomly matched to 180 who did not initiate PrEP (i.e., “controls”) by date of STI.

Conclusion

Discussion and initiation of PrEP were rare in association with healthcare encounters for STIs. Not all individuals with STIs will benefit from starting PrEP, but interventions are needed to improve low rates of sexual history-taking and discussion of PrEP during healthcare encounters for STIs.

Disclosures

Bruce Alexander, PharmD, Bruce Alexander Consulting (Independent Contractor)
869. A Qualitative Review of Social Barriers Impeding Retention in HIV Care at a Ryan White Clinic
Authors: Florakis Eleni , Johanna Smith , Kennedy Alyssa , Spacek Lisa A
Published: December 2021

Background

Ending the HIV Epidemic: A Plan for America aims to decrease new HIV diagnoses 75% by 2025 and 90% by 2030. To achieve this, we identified patients unable to achieve viral suppression with social-behavioral needs deemed ‘high-hanging fruit.’ Via extensive outreach efforts and creation of shared problem solving, we pursued the goals of rapid and effective treatment leading to viral suppression and prevention of HIV transmission. We (1) exhausted all avenues of outreach to re-engage patients in HIV care and (2) identified personal or social characteristics related to difficulties in visit retention and achieving viral suppression.

Methods

Of 446 Ryan White-eligible patients seen in an urban, academic medical center, 46 did not achieve and/or maintain viral suppression, and qualified for the study. We conducted a mixed methods survey comprised of both multiple choice and open-ended questions to ascertain what barriers patients face to continuous engagement in care and to achieving viral suppression. We developed a re-engagement outreach cycle which included: text messages and phone calls, electronic messages via patient portal or email, phone call to pharmacy to cross-check contact information, outreach to patients’ emergency contact, and sending a letter by mail.

Results

Of 46 participants, 32 were reached and 14 were not found. Sixteen re-engaged in care and of these, 14 completed the survey (see Figure). Those who completed the survey noted the following barriers to care: poor mental health, financial issues, problems committing to an appointment due to work/family/transportation, and COVID-19. Out of all 46 participants, the 14 who were not found had an overall a higher index of chaos. This index of chaos included, but was not limited to: homelessness, IV drug use, domestic violence, and stigma.

Outreach to re-engage in HIV care

A. Participants in study, B. Outreach outcomes, C. Common survey themes

Conclusion

Intensive efforts are required to re-engage patients, counsel on adherence, and achieve viral suppression. The reasons for lack of engagement in care are real and challenging. Multiple cycles of continuous outreach serve to establish trust, address barriers, and connect to HIV care.

Disclosures

All Authors: No reported disclosures
903. A Real-world Study Assessing the Risk of Lipid Changes and Other Metabolic Effects Associated with Integrase Inhibitor-based Antiretroviral Therapy
Authors: Gruss Zachary , Stone Tyler , Johnson James , Morse Caryn , Williamson John
Published: December 2021

Background

Integrase inhibitor (INSTI)-based antiretroviral therapies (ART) are first-line for HIV infection. Recent studies have identified metabolic complications of INSTI regimens, especially when TAF is included. The objective of this study was to assess lipid changes associated with INSTI-based ART.

Methods

This was a retrospective, observational, single-center study. Patients age ≥ 18 with HIV infection, receiving care Jan 2004 to Jul 2019, and prescribed the same ART for ≥ 6 consecutive months were randomly selected from a computer-generated list. Unique ART regimens prescribed per patient were considered “exposures”. Patients were followed up to 2 years per exposure. INSTI-based exposures included an INSTI plus one or more NRTI. Non-INSTI-based exposures included a PI or NNRTI plus one or more NRTI. Lipid panel results were recorded before and during exposures. Lipid changes with INSTI and non-INSTI exposures were compared. Other metabolic outcomes were recorded.

Results

192 exposures were identified (99 INSTI, 93 non-INSTI) among 132 patients. The majority were Black (69.3%) and male (61.9%). Mean age and BMI were 42.0 ± 11.3 and 26.2 ± 5.5 kg/m2, respectively. 72 (37.5%) were ART-naïve. 53.5% INSTI recipients received BIC or DTG. Hypertriglyceridemia (HTG) occurred more often during INSTI exposures (13.1% vs 4.3%; p = 0.031). Mean change in TG concentration was +10.1 and -15.0 mg/dL for INSTI and non-INSTI regimens, respectively (p = 0.105). Patients receiving INSTIs were more commonly prescribed a new lipid-lowering therapy (LLT) or an increase in dose of preexisting LLT (14.1% vs 2.2%; p = 0.003). Of those that received an INSTI-regimen and either TAF, TDF, or no tenofovir, 17.4%, 10.3%, and 8.3% developed HTG, respectively (p = 0.49). There was no difference between groups in HDL or LDL changes. Among INSTI and non-INSTI groups, weight increased by +3.8 and +2.1 kg, respectively (p = 0.129). Mean weight change was less in INSTI recipients whose regimen included TDF (+1.4 vs +4.8 kg; p = 0.053).

Conclusion

Treatment with INSTI-based ART was associated with HTG. LLTs were utilized more often among INSTI recipients, and this limited our ability to fully characterize lipid changes in this real-world study. Weight gain among INSTI recipients may be attenuated if TDF is included in the regimen.

Disclosures

James Johnson, PharmD, FLGT (Shareholder) Caryn Morse, MD, Chimerix (Scientific Research Study Investigator)Covis Pharma (Scientific Research Study Investigator)Gilead Sciences Inc. (Scientific Research Study Investigator)Ridgeback Biotherapeutics (Scientific Research Study Investigator)Roche (Scientific Research Study Investigator)SCYNEXIS, Inc. (Scientific Research Study Investigator)Theratechnologies (Advisor or Review Panel member)Viiv (Advisor or Review Panel member)
913. Re-engagement using Historical Hepatitis C Antibody Results: Is it Worth the Effort?
Authors: Osborne William , Sheikh Noorann , Botterill Gemma , Bufton Sally , Mutimer David , Tahir Mamoona , Atabani Sowsan F
Published: December 2021

Background

The World Health Organisation aim to eliminate hepatitis C (HCV) as a public health concern by 2030. One aspect of Public Health England’s (PHE) strategy to meet this target is to use historical surveillance data of anti-HCV positive patients identified by PHE to re-engage with offers of PCR testing and treatment if RNA-positive. Operational Delivery Networks (ODN) are responsible for enacting this initiative across 22 regions in England. We present an interim analysis and evaluation of the effectiveness of using this data to re-engage HCV-infected persons in the West Midlands ODN of England.

Methods

A dataset of historical anti-HCV positive antibody patients provided to the West Midlands ODN by PHE was cross-referenced with HCV RNA data from 01/01/1996 to 01/01/2019 from 5 regional laboratories and regional treatment databases. If HCV RNA positive, letters were sent to the general practitioner and to the patient to invite them for further testing and, if necessary, treatment to achieve SVR. This received no additional funding or support and occurred in addition to the routine clinical workload.

Results

From a dataset of 4,540 anti-HCV antibody results, 31.7% (n=1,440) had a PCR result: 48.1% (n=693) were PCR positive for HCV RNA with no evidence of cure. 693 letters were sent to GPs from Oct 2019 to Feb 2020 with responses from 14.2% (n=99). From July to Oct 2020 only 212 patient letters were sent (due to significant interruption due to the COVID-19 pandemic) and 11.3% (n=24) replied by May 2021. 17 presented for PCR testing and 4 were found to be viraemic. To date, one patient has achieved SVR and three have completed treatment awaiting SVR.

Re-Engagement Process

Flow diagram of re-engagement of patients with historical antibody-positive results for hepatitis C virus. * Of the 17 deemed not suitable to contact by the GP: 4 treated elsewhere, 3 had negative PCR elsewhere, 1 was unknown reason, 2 were under care of another hospital, 7 had died

Conclusion

The use of historical anti-HCV antibody results to re-engage people into testing and treatment for hepatitis C in this format is low yield. Rollout was limited by ongoing clinical work and the COVID-19 pandemic. Dedicated time and resources with a less restrictive cohort might improve yields.

Disclosures

All Authors: No reported disclosures
921. Acute HAV Infection in an Inpatient Psychiatry Unit
Authors: Weston Gregory , Boland-Reardon Carmel , Rhoden Renee , Ogbonna Rose , Sirichand Surksha , Gendlina Inessa , Gendlina Inessa , Corpuz Marilou
Published: December 2021

Background

The incidence of hepatitis A virus (HAV) infection has been rising in the US since 2016, and in New York State since 2019. New York City has also seen an increase of HAV infection among high risk populations. We present a case of acute HAV infection in an inpatient psychiatry unit which has its own unique isolation and management challenges.

Methods

A patient was admitted on 3/21/21 from a group home. He developed abdominal pain, diarrhea and vomiting on 4/15, with elevated liver function tests (LFT). He was transferred to Medicine on 4/17 and HAV IgM and IgG resulted positive on 4/18. Visitation to the unit has been halted for over a year, and no outside food has been allowed. The patient has not been observed to have any sexual exposure to others.

Investigation

Exposure window: 15 days prior to start of symptoms. Patients in the unit were screened for symptoms, tested for HAV IgM/IgG, LFTs. Discharged patients were contacted and referred straight for vaccination (difficult to have multiple visits). Staff members with contact to the unit were screened, via email and phone calls. If no previous vaccination and there was presence of exposure or symptoms, staff were referred to Occupational Health Services (OHS). Other Measures: The unit was terminally cleaned and daily enhanced cleaning with bleach ensued. Daily assessment of patients and staff for symptoms. Admissions were held for 2 days until all the patients were tested and given vaccine. Further admissions were screened for HAV.

Results

32 inpatients screened. One patient was positive for HAV IgM, but was asymptomatic with normal LFTs. On investigation, patient had acute hepatitis in February 2021. Patients with no immunity were vaccinated. Two immunocompromised patients were also given HAV immunoglobulin. On chart review, 6 out of 29 discharged patients had evidence of immunity. 133 staff were screened and 54 referred to OHS (see table).

Exposure Investigation

Conclusion

As evident with numerous COVID outbreaks in inpatient Psychiatry units, communicable diseases are difficult to control. Patients are in an interactive communal setting and participate in group sessions. For better care and safety of patients and staff, our unit will screen and offer HAV vaccine to new admissions.

Disclosures

Gregory Weston, MD MSCR, Allergan (Grant/Research Support) Inessa Gendlina, Nothing to disclose
938. Azole Resistant Aspergillus Species in Lung Transplant Recipients: A 10 Year Experience
Authors: Marschalk Nicholas A , Samanta Palash , Kwak Eun Jeong , Nguyen Minh-Hong
Published: December 2021

Background

Invasive aspergillosis (IA) causes significant morbidity and mortality in lung transplant (LTx) recipients. Antifungal resistance in Aspergillus species is on the rise globally with specific concern in Europe related to the TR34/L98H mutation in the cyp51A enzyme that induces pan-azole resistance. Azole exposure is a known risk factor for development of resistant Aspergillus, but this is less well described in LTx population.

Methods

We reviewed the electronic medical records of LTx patients with respiratory cultures positive for Aspergillus species known to be inherently resistant or any Aspergillus species tested to be resistant to one or more triazole from 2010 to 2019. For available isolates, Sanger sequencing was performed on cyp51A with primers targeting the promoter region and 3 known hotspot areas.

Results

Twenty eight patients met inclusion criteria and 2.7% (28/1026) Aspergillus isolates were azole-resistant during study period (Figure 1). Median time from LTx to resistant Aspergillus growth was 196 days (range 14 - 3146). There was a cluster of positive cultures within 1-year post-Tx period (13/28). Azole exposure varied, from 7 to 2443 days (median 128). There was no change in incidence over the study period. The most common species was Aspergillus calidoustus (Figure 2). Twenty cases were deemed colonization, vs 5 probable IFI and 3 proven IFI. Mortality of IFI with resistant Aspergillus was 38% (3/8), higher than azole-susceptible IA (p=0.05). Twelve isolates were available for sequencing; none carried TR34/L98H mutation. There was wide variation in mutations, ranging from 1 to 12 point mutations in the cyp51 enzyme, many of them SNPs previously described as engendering an azole resistant phenotype (Figure 3).

Aspergillosis-free Survival by Resistant and Susceptible Isolates

Development of azole-resistant aspergillus colonization/infection was rare relative to common occurrence of colonization/infection with susceptible isolates in the lung transplant recipient population

Azole Resistant Aspergillus Species Isolated from Lung Transplant Recipients

The most commonly isolated species were A. calidoustus and ustus. Only 4/28 isolates were A. fumigatus.

Azole Resistant Aspergillus Genotypic Analysis

Sequenced isolates showed wide variability in point mutations. M220V, G54, and G448 were the only mutations observed more than once. 3 isolates were wild type.

Conclusion

Azole resistant Aspergillus infections remain an uncommon problem in LTx. The majority of isolates were deemed colonization, but mortality was high when IFI was present. Most isolates had mutations within the hot spot regions of cyp51A known to induce azole resistance. There were no TR34/L98H mutants found in our patient population.

Disclosures

Minh-Hong Nguyen, MD, Merck (Grant/Research Support)