bluuebunny/crossref_metadata_2025_split huggingface dataset:
1000. HIV and the Treatment-Experienced Patient: The Positive Impact of Case-Based Education on Physicians’ Competence and Confidence
Authors: Hurst Simi Thomas , Blatherwick Don 
Published: January 2021

Abstract

Background
Despite therapeutic advances, treatment-experienced HIV patients can present a clinical challenge, even to experienced care providers.
Table. Assessment of Educational Effectiveness

Methods
This study assessed the ability of digital education to improve HIV/ID specialists’ ability to develop tailored strategies for treatment-experienced patients. A CME/ABIM MOC/CE-certified, case-based, educational program was developed. Modeled after the interactive grand rounds approach, a “test then teach” strategy with multiple choice questions was used to elicit cognitive dissonance. Evidence-based feedback was provided following each response. Educational effectiveness was assessed with a repeated-pairs pre-/post-assessment study design; each individual served as his/her own control. A chi-square test assessed changes pre- to post-assessment. P values &lt; 0.05 are statistically significant. Effect sizes were evaluated using Cramer’s V (&lt; 0.05 modest; 0.06-0.15 noticeable effect; 0.16-0.26 considerable effect; &gt; 0.26 extensive effect). The activity launched on a website dedicated to continuous professional development on 09/12/19. Data for this matched-learner analysis were collected through 11/06/19.

Results
To date, 14,181 HCPs (3128 physicians; 9518 nurses/NPs; 333 PAs; 172 pharmacists) have participated in the activity. Data from the subset of HIV/ID specialists (n=110) who answered all pre-/post-assessment questions during the initial study period were analyzed. Following activity participation, significant improvements were observed in the proportion of HIV/ID specialists who answered all assessment questions correctly (15% pre vs 81% post; P &lt; .0001; V=.356). Improvements were also observed in several specific areas of assessment (Table). Additionally, 44% of HIV/ID specialists indicated they planned to modify their treatment approach for treatment experience patients because of participating in the education.Of note, this assessment also identified topics in which HIV/ID had a high degree of baseline knowledge.

Conclusion
Participation in this online, interactive, case-based, program significantly improved HIV/ID specialists’ ability to develop individualized care strategies for patients who are treatment experienced.

Disclosures
All Authors: No reported disclosures
74. Interrupted Time Series Analysis of the Impact of Fluoroquinolone Cascade Reporting
Authors: Nestler Matthew , Markley John D , Noda Andrew , Godbout Emily , Kim Jihye , Lee Kimberly B , Doern Christopher , Doern Christopher , Bryson Alexandra L , Doll Michelle , Bearman Gonzalo , Stevens Michael 
Published: January 2021

Abstract

Background
Cascade reporting is a form of selective reporting where antibiotic susceptibility results are revealed in a sequential order to optimize antibiotic use. On May 1, 2019, Virginia Commonwealth University Health implemented cascade reporting for ciprofloxacin and levofloxacin for E. coli from urine cultures. We hypothesize that suppressing fluoroquinolone (FQ) results for urine isolate E. coli susceptibility panels using cascade reporting led to a decrease in the overall rate of inpatient FQ use.

Methods
We compared inpatient FQ use (in days of therapy (DOT)/1000 patient days (PD)) for the one-year pre-cascade period (May 2018-April 2019) to the one-year post cascade period (May 2019-April 2020). Inpatient FQ use for May 2018-April 2020 was modeled as an interrupted time series (ITS) using ordinary least squares regression. The regression model followed the form of Y = B0 +B1T + B2 X + B3 XT with Y = (DOT/1,000 PD), T = time in months, X = cascade reporting represented with a binary digit, and XT= time since cascade reporting was implemented. Results were examined for autocorrelation and lag effects. Analysis conducted using Microsoft Excel and Python Statsmodel library v0.11.1.

Results
A segmented regression model was successfully fitted with R^2 = 0.73 (Figure 1). The pre-intervention slope (T), intervention change (X), and post-intervention slope (XT) were -3.9, -2.3, and 3.8 DOT respectively. A significant positive change in pre versus post intervention slope was detected (p = 0.01).

Conclusion
Results showed no significant change in FQ DOT/1000 PD when cascade reporting was implemented in May 2019. This may be due to empiric prescribing of FQs in the inpatient setting, due to the fact the rate of FQ use was already decreasing prior to cascade reporting adoption, or due to other factors.
We detected a significant positive change in the slope of FQ from -4 to 4 DOT/1000 PD each month post-cascade reporting. Our hospital has had a decrease in FQ use over the past 8 years so this may be due to a ‘floor’ effect where the true minimum of necessary FQ use was reached; further investigation is warranted. We believe our data will be of interest to other Antimicrobial Stewardship Programs considering cascade reporting.

Disclosures
All Authors: No reported disclosures
1008. Disease Severity Impact on Long-Term Virologic Response to Ibalizumab in Expanded Access Protocol (TMB-311)
Authors: Kumar Princy , Leider Jason , Slim Jihad , Moyle Graeme , Leonard Maurice , Cash R Brandon , Weinheimer Steven , Mesquita Pedro 
Published: January 2021

Abstract

Background
The principal goal of antiretroviral therapy (ART) is durable suppression of HIV RNA. In treatment-experienced (TE) patients, ongoing viremia can lead to further accumulation of drug resistance, increased morbidity and mortality. ART efficacy often depends on HIV disease severity; therefore, we sought to assess its impact on long-term virologic suppression in patients treated with Ibalizumab (IBA), the first long-acting, post-attachment inhibitor approved for multi-drug resistant (MDR) HIV-1 treatment.

Methods
In TMB-301, a Phase 3 study, 40 TE patients with viral load (VL) &gt;1000 copies/mL (c/mL) received an intravenous (IV) loading dose of IBA (2000mg) followed by maintenance doses (800mg IV) every 2 weeks combined with an optimized background regimen. Patients who completed TMB-301 in the US (n=27) continued to an expanded access protocol TMB-311. To determine the impact of baseline (BL) disease on long-term virologic response, we conducted an on-treatment analysis stratified by BL VL and CD4 count up to week 96. Differences in the proportion of suppressed (&lt; 50 c/mL) individuals among the strata were assessed by Fisher’s exact test.

Results
Median BL VL and CD4 count were 35,350 c/mL and 73 cells/mL, respectively. The number of patients in the VL strata were 11, 17 and 12 for VL &lt; 10,000, 10,000-70,000, and &gt;70,000 c/mL, respectively. There were 12, 10, 5 and 13 patients in the subgroups with CD4 count &lt; 10, 10-100, &gt;100-200 and &gt;200 cells/µL. Population disease severity was reflected by four deaths (unrelated to study drug). Overall, the proportion of suppressed patients increased from 55% at week 24 (n=31) to 75% for patients remaining on treatment for 96 weeks (n=20). Median VL decrease was 2.9 log10 c/mL. Notably, no statistically significant differences were found across groups. Among patients with advanced HIV disease, 66.7% with CD4 count &lt; 10 cells/mL and 71.4% with VL &gt;70,000 c/mL at BL remained fully suppressed at week 96.

Conclusion
In TE patients with advanced HIV disease, maximal viral suppression with IBA was observed regardless of BL CD4 or VL strata if patients remained on treatment. This demonstrates that TE patients across the spectrum of HIV disease, can achieve viral suppression by using drugs with a new mechanism of action.

Disclosures
Princy Kumar, MD, Gilead Sciences Inc. (Scientific Research Study Investigator) Jason Leider, MD, PhD, THERA (Speaker’s Bureau) Jihad Slim, MD, Abbvie (Speaker’s Bureau)Gilead (Speaker’s Bureau)Jansen (Speaker’s Bureau)Merck (Speaker’s Bureau)ViiV (Speaker’s Bureau) Graeme Moyle, MD, Theratechnologies (Consultant) Maurice Leonard, PhD, Theratechnologies Europe Ltd (Employee, Shareholder) R Brandon Cash, PharmD, Theratechnologies (Employee) Steven Weinheimer, PhD, TaiMed Biologics USA (Employee) Pedro Mesquita, PhD, Theratechnologies, Inc. (Employee)
1013. Enhanced Oral Health Care Services for PLWHA - Midlands Region, South Carolina
Authors: Baello Christina M , Ahuja Divya , Finkley Norlica , Rao Rajee 
Published: January 2021

Abstract

Background
An estimated 58- 64 % of people living with HIV/AIDS (PLWHA) do not receive regular dental care and this gap may be attributed to barriers related to cost, access to dental care, logistical issues, indifference to or fear of dental care.1,2 The Immunology Center at Prisma- University of South Carolina, School of Medicine is a Ryan White funded Part B Program that provides care to &gt; 2400 PLWHA. Based on the perceived barriers, an enhanced oral health care program was implemented in 2018, wherein patients in need of dental care and meeting inclusion criteria are referred to contracted local general dentistry and specialty practices.

Enhancements
Dedicated Dental Services Coordinator (DSC)
Facilitated transport to and from the dental clinic
Annual budget of $2700 per patient
Access to dental specialties (oral and maxillofacial surgery)
Restorative services (crowns, dentures and root canals)

Program Goals
The ultimate goal of the oral health care program is to provide biannual dental prophylaxis and expanded restorative services to PLWHA.

Inclusion criteria for referrals
1 Virological suppression over 6 months. (HIV Viral Load &lt; 200 c/mL)
2 Adherence with HIV clinic appointments.
Midlands Region, South Carolina

Methods
The DSC completes the following: monitoring of referrals, patient compliance to program inclusion criteria, linkage to dental care, payments for dental services, and coordination with case management.

Results
Between 2018 and 2019, 535 patients were referred to the oral health care program. Almost 75% 399 completed at least one dental clinic visit. The average number of visits for patients from their enrollment date (2018-2019 to December 2019 was 1.56, with an average of 8.08 services, and 1.13 prophylaxis visits with their oral health care provider. Patients were predominantly African American and male but were spread across a wide age spectrum and 8 counties. Nearly 94% of patients remained virologically suppressed during their oral health care treatment.
Table 1: 2018-2019 Program Summary of Oral Health Care

Table 2 & Figure 1: Oral Health Care Patients by Age Group, Figure 2: Oral Health Care Patient by Gender

Table 3 & Figure 3: Oral Health Care Patients by Race and Ethnicity, Table 4 & Figure 4: Oral Health Care Patient by County

Conclusion
PLWHA have high rates of unmet oral health care needs and low utilization of oral health services. Adequate resources and coordination of care with local dentists can overcome traditional barriers and improve access to dental care.

Abstract References

Disclosures: All Authors: No reported disclosures
1016. Global trends in Integrase Strand Transfer Inhibitor resistance among HIV-1B Infected Patients
Authors: Gurley Stephen A , Nguyen Minh Ly , Anderson Albert 
Published: January 2021

Abstract

Background
Integrase strand transfer inhibitors (INSTIs), a new class of antiretroviral (ART) therapy for HIV, have quickly become a cornerstone of ART regimens globally. Here, we present the prevalence of INSTI resistance globally and over time among people living with HIV/AIDS (PLWHA), clade B.

Methods
To characterize trends in INSTI resistance, we conducted a literature search of articles published after 2010 via Pubmed and posters/abstracts from the Conference on Retroviruses and Opportunistic Infections (CROI) from 2016-2020. Included in our analysis are studies that include more than 100 individuals with INSTI resistance testing, who are infected with HIV clade B. We stratified the studies by country and by time period. We defined two time periods, 2008-2015 during which primarily first generation of INSTI were used (raltegravir and elvitegravir), and 2015-2020 during which second generation INSTIs (dolutegravir and bictegravir) use became widespread. We considered drug-resistance associated mutations (DRAM) in both ART-naive and in ART-experienced PLWHA.

Results
Overall, we reviewed 31 papers and 11 CROI abstracts that met the inclusion criteria. We observed that prevalence of DRAM in naïve patients is low globally and has remained low over time, ranging from 0%-8%. Meanwhile, we observed a downward trend in DRAM among INSTI-experienced patients from the 2008-2015 period to the 2015-2020 period from 11%-47.6% to 8%- 32.1%, reflecting higher barrier to resistance described in vivo among the 2nd generation INSTIs. See table below.
INSTI Resistance Summary Results Table

Conclusion
Here, we have analyzed the trends in INSTI prevalence over time and in different countries for HIV1 clade B. We demonstrate that globally, INSTI DRAM among INSTI-naïve patients are rare and incidence does not increase significantly over time despite increased usage. In addition, published studies showed a downward trend in INSTI DRAM among INSTI-experienced patients after 2015, reflecting the higher barrier to resistance in the second generation INSTIs. The most commonly occurring INSTI DRAMs observed were N155H (more common in the era of f1st generation INSTI), Q148H/K/R, and G140S. As INSTI usage continues to increase globally, continued vigilance and surveillance is needed to monitor continued INSTI resistance over time.

Disclosures
All Authors: No reported disclosures
1019. Healthcare Resource Utilization and Cost of People Living with HIV (PLWH) in US Commercial and Medicare Advantage Health Plans
Authors: Priest Julie , Hulbert Erin , Gilliam Bruce L , Burton Tanya 
Published: January 2021

Abstract

Background
The goal of HIV treatment is to achieve and maintain virologic suppression to prevent disease progression. Patients with uncontrolled HIV and decreasing CD4 counts can experience more health problems and increased health care resource utilization (HCRU) and cost. The objectives were to describe the clinical characteristics, HCRU and cost of PLWH in US Commercial and Medicare Advantage health plans by CD4 count.

Methods
A retrospective cohort study of PLWH aged 18+ between 01/01/2014-03/31/2018 in the Optum Research Database was conducted. Patients were continuously enrolled 6 months before (baseline) and 12 months after (unless evidence of death) the first identified antiretroviral (ARV) therapy (follow-up). Patients were classified as heavily treatment-experienced (HTE) if their regimen indicated an ARV therapy used to treat multi-drug resistant (MDR) virus, Non-HTE if treatment did not include an HTE regimen, or Treatment-Naïve if they were not treated with any ARV medication during baseline. All variables were summarized descriptively by the CD4 count closest to the first ARV regimen and compared using chi-square or F-test/ANOVA.

Results
5,522 patients met the inclusion criteria including 18% with a CD4 count &lt; 200, 70% 200-500, and 12% &gt; 500 cells/mm3. Patients in the lowest CD4 group were more likely to be HTE or Naïve, African-American, female, living in the South, earn less and have at least one AIDS defining condition (Table 1). Patients in the lowest CD4 group also had the highest mortality rate, (6% in the &lt; 200, 2% 200-500, 1% in the &gt; 500 group; p-value &lt; 0.001) and the highest rates of emergency room visits and inpatient stays (Figure 1). All-cause total cost among patients with CD4 counts &lt; 200 was 51% higher than those with CD4 &gt; 500, and medical cost was 207% higher driven primarily by inpatient health care cost. Similar trends were seen for HIV-related care. Among the lowest CD4 group, average total cost was highest in the HTE group followed by Naïve patients.
Table 1. Baseline Characteristics by CD4 count group, cells/mm3

Figure 1. Percentage of Patients with All-cause and HIV-related Healthcare Utilization by CD4 Group

Conclusion
There are still PLWH with CD4 counts &lt; 200 cells/mm3 which can result in more AIDS defining conditions, higher mortality risk, and higher HCRU and cost. These results suggest interventions may be needed to diagnose and treat patients sooner and closely monitor the health of more advanced patients for worsening outcomes.

Disclosures
Julie Priest, MSPH, GlaxoSmithKline (Employee, Shareholder) Erin Hulbert, MS, Optum (Employee)ViiV (Grant/Research Support) Bruce L. Gilliam, MD, ViiV Healthcare (Employee)
1022. Impact of Hospitalization on Antiretroviral Therapy for People Living with HIV
Authors: Ladak Amber , Young Henry N , Tang Emily , Curtis Jessica , Chastain Daniel B 
Published: January 2021

Abstract

Background
Persons living with HIV (PLWH) are frequently hospitalized for reasons often unrelated to HIV. Transitioning of antiretroviral therapy (ART) while inpatient may not always be an immediate priority due to lack of knowledge, formulary restrictions, and patient status. This could lead to medication errors and gaps in therapy, which can persist at discharge, and could lead to viral rebound and disease progression. The purpose of this study was to identify effects of hospitalization on ART for PLWH.

Methods
This was an IRB approved, multi-center, retrospective cohort study of patients with HIV and/or AIDS based on ICD codes. Patients were included if they were at least 18 years old, receiving outpatient ART prior to admission, and hospitalized between March 2016 and March 2018. Patients were excluded if they were pregnant and only received intravenous zidovudine during their hospitalization. The primary objective was to determine the rate of ART restarted during hospitalization. Secondary objectives included rate at which inpatient ART was modified compared to outpatient regimen, and risk factors associated with regimen modification.

Results
Of 400 patients screened, 295 (74%) patients were on an outpatient ART regimen and were included in the study. Approximately half, 51%, were on a single tablet regimen (STR) outpatient. This population was majority male (59%) and of black race (87%). Median age was 49 years. Median CD4 count was 160 cells/mm3, while median HIV RNA for those with detectable viral load was 57,095 copies/mL.
236 of 295 patients (80%) received ART during their inpatient stay. However, 70 (30%) of these patients received a regimen that differed from their outpatient ART regimen. 69% of regimens were modified for reasons other than to optimize therapy. Patient sex, place of admission, and receipt of a STR or multi-tablet regimen (MTR) as an outpatient did not significantly impact rate of regimen modification.

Conclusion
Ensuring appropriate transition of ART during hospitalization remains an area in need of improvement. No one specific factor was associated with whether outpatient ART was appropriately and accurately restarted during hospitalization. Thus, there are many opportunities to improve transitions of care and antiretroviral stewardship.

Disclosures
All Authors: No reported disclosures
1023. Impact of Physical Therapy in the Management of Musculoskeletal Pain in HIV Patients
Authors: Sebanayagam Vinoja , Chakur Nichole , Weinberger Jarrett , Twardy Brandon S , Veltman Jennifer 
Published: January 2021

Abstract

Background
Musculoskeletal (MSK) pain is common in HIV patients in the ambulatory setting. Healthcare providers tend to prescribe opioids to control MSK pain in HIV patients, which increases the risk of opioid misuse. An interdisciplinary approach that includes physical therapy has been successful in managing MSK pain in various healthcare settings. Therefore, we sought to find the impact of recruiting a physical therapist (PT), on the number of opioid prescriptions and physical therapy referrals made by resident physicians to manage MSK pain in HIV patients.

Methods
We performed a retrospective chart review of all patients seen by Internal Medicine (IM) residents in an HIV clinic in Detroit, before (01/17-05/17; 2017 dataset) and after (01/18-05/18; 2018 dataset) recruiting a physical therapist to the healthcare team. We collected demographic and clinical data from both datasets. We also surveyed the residents to assess how the PT addition influenced their comfort and knowledge in treating MSK pain in HIV patients. IRB waiver was obtained.

Results
Results showed that of all HIV patients seen at the clinic, 28/249 (11%) and 37/178 (21%) had chronic MSK pain in the 2017 and 2018 datasets, respectively. In 2017, all 28 patients with MSK pain were prescribed opioids. This number significantly decreased in 2018 after the PT addition (10/37 patients; p&lt; 0.0001). Moreover, the number of physical therapy referrals made by residents significantly increased after the PT addition (2017: 5/28 patients; 2018: 17/37 patients; p=0.03). Residents also recommended non-opioid interventions including orthopedics referrals (7/37 patients), braces/orthotics (3/37 patients) and non-opioid analgesics (26/37 patients) to patients after the PT addition. Survey responses showed that 7/9 residents (78%) felt that the physical therapist was helpful in improving their examination skills or developing a treatment plan for patients.
The effect of recruiting a physical therapist on the number of opioid prescriptions and physical therapy referrals made by resident physicians

Conclusion
In conclusion, our results show that the addition of a physical therapist to the team encourages physicians to utilize non-opioid management of MSK pain in HIV patients. We also find that physicians are satisfied with taking an interdisciplinary approach to pain management in HIV patients.

Disclosures
All Authors: No reported disclosures
77. Out of Sight, Out of Mind: Impact of an Antimicrobial Stewardship Bundle on Fluoroquinolone Utilization
Authors: Black Blade W , Harding Stephanie , Beadle Kathy 
Published: January 2021

Abstract

Background
Fluoroquinolones are broad spectrum antimicrobials associated with a growing list of adverse effects, such as Clostridioides difficile infection, arrhythmias, central nervous system effects, tendon rupture and aortic aneurysm. Due to increasing concerns regarding adverse events and growing resistance, the antimicrobial stewardship team at Wesley Healthcare implemented a bundle aimed at reducing fluoroquinolone usage beginning in June 2017. The components of this bundle included suppression of fluoroquinolone susceptibility in Enterobacteriaceae isolates, removal of fluoroquinolones as first line options on order sets, and introduction of a respiratory specific antibiogram.

Methods
The objective was to evaluate the impact of the stewardship bundle on fluoroquinolone utilization. The primary outcome was ciprofloxacin and levofloxacin usage in days of therapy per 1000 inpatient days (DOT) collected at monthly intervals for 24 months before and after intervention. Overall antimicrobial usage in DOT served as a control variable. The secondary outcomes were E. coli and P. aeruginosa susceptibility to ciprofloxacin measured at the same time points as the primary outcome. An interrupted time-series analysis using segmented regression was performed for all variables.

Results
The mean monthly levofloxacin usage was reduced from 14.1 (95% CI, 12.7 - 15.4) to 8.4 (95% CI, 7.6 - 9.3) DOT. The mean monthly ciprofloxacin usage was reduced from 26.9 (95% CI, 24.6 - 29.4) to 15.8 (95% CI, 14.0 - 17.5) DOT. The trend in levofloxacin usage was reduced (p=0.035), while a pre-existing downward trend in ciprofloxacin usage was unchanged (p=NS). Overall antimicrobial usage increased, likely due to increasing hematology/oncology populations during the study period. There were no differences in E. coli or P. aeruginosa susceptibilities observed.

Conclusion
This antimicrobial stewardship bundle may be a useful intervention to reduce fluoroquinolone usage. The bundle may be of particular utility in reducing levofloxacin usage, as our results demonstrated a change in both its usage and trend in usage.

Disclosures
All Authors: No reported disclosures