bluuebunny/crossref_metadata_2025_split huggingface dataset:
47. Long Term Outcomes of Pulse-taper Corticosteroid Therapy (PCT) for Refractory Non-HIV Cryptococcal Meningoencephalitis
Authors: Anjum Seher , Williamson Peter , Magone Teresa , Edmond Fitzgibbon , Krieger Chantal , Murphy Elizabeth , Zalewski Chris , King Kelly , Chisholm Jennifer , Brewer Carmen , Nath Avindra , Billioux Jean , Kosa Peter , Bielekova Bibiana , Bennett John , Marr Kieren , Hammoud Dima , Dean Owen , Kim Jeff 
Published: January 2021

Abstract

Background
Cryptococcal meningoencephalitis (CM) is a major cause of mortality in HIV/AIDS, transplant recipients and previously healthy individuals. In the latter, a post-infectious inflammatory response syndrome (PIIRS) is associated with poor clinical response despite prior amphotericin therapy and CSF culture conversion. Data on effective treatment is limited.

Methods
Between March 2015 and March 2020, 15 patients with CM/PIIRS were treated with adjunctive pulse – taper corticosteroid therapy (PCT) consisting of intravenous methylprednisolone 1 gm daily for 1 week followed by oral prednisone 1 mg/kg/d, tapered based on clinical and radiological response plus oral fluconazole. Montreal cognitive assessments (MOCA), Karnofsky Performance scores, MRI brain scans, eye and audiologic exams were conducted at baseline and after pulse completion. CSF parameters were assessed prior to and after the pulse.

Results
80% of patients were male, median age 51 years. Median time from antifungal treatment to steroid initiation was 6 weeks. The most common symptoms at PIIRS diagnosis were progressive deterioration in mental status and vision changes. There was a significant improvement in MOCA(n=14) and Karnofsky(n=15) scores at 3 weeks (p&lt; 0.0003), which was accompanied by improvements in CSF: serum, glucose ratios, CSF WBC, protein and activated CD4 T cells (n=14) post-pulse (p&lt; 0.003). Additionally, soluble CSF IL-6 and sCD25 levels improved (p = 0.03). Neurofilament light chain levels (NFL), a biomarker of axonal damage, showed significant reductions over a 30-month period (Generalized Estimating Equation coefficient = 0.128) and a negative correlation with post pulse MOCA scores (r = - 0.8; p = 0.01).
Papilledema (n=8) and visual field deficits (n=11) improved significantly (p&lt; 0.0005) after 2 months of pulse completion. Brain MRI showed improvement of radiological findings in 11 patients (p=0.001). Five out of 7 patients who underwent audiological testing demonstrated hearing improvement after 3 weeks post-pulse. CSF cultures remained negative.

Conclusion
PCT in this small cohort of PIIRS patients was associated with persistent improvements in CM-related complications with minimal toxicity and no recurrence of infection.

Disclosures
All Authors: No reported disclosures
50. Evaluation of Discordant Results Between Filmarray Meningitis/encephalitis Panel and Conventional Testing in Pediatric Patients: A Multi-site Retrospective Cohort Study
Authors: Ekambaram Maheswari , Nabower Aleisha M , Ampofo Krow , Gollehon Nathan S , Goodrich Nathaniel , Martin Kimberly C , McCulloh Russell , Rajbhandari Prabi , Snowden Jessica 
Published: January 2021

Abstract

Background
FilmArray Meningitis/Encephalitis Panel (ME panel) has a 11% false positive and 2.2% false negative rate compared to conventional testing. We aim to describe characteristics, treatment decisions and outcomes in pediatric patients with discordant results between ME panel and conventional testing.

Methods
We conducted a multisite (n=4) retrospective review of patients &lt; 18 years with positive cerebrospinal fluid (CSF) results by ME panel or conventional testing (CSF culture, Herpes Simplex Virus [HSV] and enterovirus [EV] PCR) from time of local ME panel implementation to February 2019. We excluded CSF obtained for non-infectious reasons. Demographic and clinical data were extracted from electronic medical records. Comparison between concordant and discordant results were made using Mann-Whitney test for continuous and Fisher’s exact test for categorical variables.

Results
A total of 355 patients had at least 1 positive result. Baseline characteristics and pathogens are shown in Table 1 and 2. Of the 53 bacterial pathogens identifiable by ME panel, 31 (58%) had discordant results – 29 positive by ME panel only and 2 by culture only (both E.coli). Patients with bacterial pathogens identified by ME panel only had lower CSF WBC and protein but higher CSF glucose (Table 3). Five patients with bacteria identified on ME panel only were not treated as meningitis given lack of pleocytosis, no antibiotic pretreatment and negative repeat cultures. Of these, 4 recovered without complications but one had hypoxic encephalopathy.
Two patients had HSV noted in ME panel but individual PCR negative. The first was a 13-day-old with typical skin lesions and positive surface swab. The other was a 6-day old only with CSF pleocytosis. Both had abnormal neuroimaging and were treated as true cases. Of 24 who had both EV PCR and ME panel, 7 were positive by ME panel only and 3 by PCR only.
Table 1: Baseline Characteristics of the Study Population

Table 2: Pathogens identified via CSF Culture, ME panel or Conventional PCR

Table 3: Characteristics of Discordant Results for Bacterial Pathogens Tested in ME panel

Conclusion
More than half of bacterial pathogens identified by ME panel did not have a corresponding positive CSF culture. No difference was noted by antibiotic pretreatment. Treatment decisions based on positive ME panel should be made in the appropriate clinical context. Likewise, a negative ME panel does not rule out infection especially when atypical organisms are suspected.

Disclosures
Krow Ampofo, MBChB, Merck (Grant/Research Support)
55. Diabetes, Obesity and COVID-19 Disease: An Observational Study of Outcomes Among Hospitalized Patients in Boston, Massachusetts
Authors: Seiglie Jacqueline , Platt Jesse , Cromer Sara Jane , Bunda Bridget , Foulkes Andrea , Bassett Ingrid , Hsu John , Meigs James , Leong Aaron , Putman Melissa , Triant Virginia A , Wexler Deborah , Manne-Goehler Jennifer 
Published: January 2021

Abstract

Background
In the United States, diabetes mellitus (DM) is among the most common chronic diseases, with approximately 34.2 million people affected. DM has also emerged as a commonly reported risk factor among people hospitalized with coronavirus disease 2019 (COVID-19). In this study, we sought to evaluate whether people with DM who are hospitalized with COVID-19 were more likely to experience poor early outcomes and whether this association remained after adjustment for obesity status.

Methods
We analyzed data from the Massachusetts General Hospital (MGH) COVID-19 Data Registry. The sample included 450 people with PCR-confirmed SARS-CoV-2 infection who were hospitalized at MGH between March 11, 2020 and April 30, 2020. The primary outcomes were (1) admission to the intensive care unit (ICU) and (2) need for mechanical ventilation or death, both within 14 days of presentation to care. Data were obtained by manual chart review and via an EMR-associated database. Logistic regression was used to evaluate the relationship between diabetes and these outcomes. All models were adjusted for age, sex, race, BMI category and key comorbidities.

Results
In this study, 178 (39.6%) of 450 participants had DM and 346 (76.9%) were overweight or obese. People with DM were on average older and had a higher BMI than those without DM. A higher percentage of patients with DM were admitted to the ICU (42.1% vs 29.8%, p=0.007) and required mechanical ventilation or died (46.6% vs 27.7%, p&lt; 0.001), compared with patients without DM (Figure 1). In adjusted models, DM was associated with a greater odds of ICU admission (aOR: 1.58 [95% CI: 1.01–2.46]) and mechanical ventilation or death (2.15 [1.38–3.34). Obesity was associated with a greater odds of ICU admission (2.15 [1.20–3.86]) but not with mechanical ventilation or death (1.52 [0.87–2.67]). Table 1 provides the model results in full.
Figure 1. ICU Admission and mechanical ventilation or death within 14-days by diabetes status among 450 people hospitalized with COVID-19

Conclusion
Diabetes was associated with poor outcomes within 14-days of presentation to care for COVID-19. These findings remained after adjustment for obesity. Our findings can help guide risk mitigation efforts and patient-centered care decision making for people with DM and obesity, particularly in areas of the US that have a high prevalence of DM and obesity and are in early phases of the SARS-CoV-2 outbreak.

Disclosures
Sara Jane Cromer, MD, Depuy-Synthes (a Johnson & Johnson company) (Employee) James Meigs, MD, Quest Diagnostics (Other Financial or Material Support, Academic Associate) Deborah Wexler, MD, Novo Nordisk (Other Financial or Material Support, Data Monitoring Committee)
63. Prognosis of COVID-19 Patients with Diabetic Ketoacidosis with or Without Hyperosmolar Hyperglycemic State
Authors: Chan Kok Hoe , Thimmareddygari Divya , Ramahi Amr , Atallah Liana , Slim Jihad 
Published: January 2021

Abstract

Background
One of the risk factors for poor outcome with SARS-CoV-2 infection is diabetes mellitus; diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the most serious complications of diabetes mellitus. We aimed to explore the clinical characteristics and outcomes of COVID-19 patients presenting with isolated DKA or combined DKA/HHS to our institution.

Methods
A retrospective, hospital based observation case series was performed on patients with SARS-CoV-2 admitted to Intensive Care Unit between 03/20/20 and 04/20/20. Inclusion criteria were: 1) Blood Glucose &gt;250mg/dL; 2) Serum bicarbonate &lt; 18 mmol/L; 3) Anion Gap &gt;10; 4) serum pH &lt; 7.3; 4) ketonemia or ketonuria; and 5) positive SARS-CoV-2 RT-PCR. Hyperosmolality, on the other hand, was defined as an effective/calculated plasma osmolality &gt;304 mOsm/kg.

Results
A total of 87 patients with COVID-19 were admitted to the ICU during the study period, 12 of them had either isolated DKA or DKA/HHS. Baseline demographics, lab values and outcome are summarized in Table 1. Six of the patients had isolated DKA and six had combined DKA and HHS. The median age for the patient was 49.5 years old (range from 19 to 62 years old). The male to female ratio was 5:1. Of the 12 patients, 10 patients (83%) had a history of DM, nine were type 2 and only one type 1; two patients were newly diagnosed DM, presenting as DKA, presumptively precipitated by COVID-19. Five patients (42%) had a BMI &gt;30 kg/m2. As for ethnicity; seven were Hispanic (59%), four African American (33%), and one Caucasian (8%).
Patients with combined DKA/HHS, higher BMI, higher HbA1c, severe acidosis tended to have higher mortality. The striking feature was that isolated DKA or combined DKA/HHS was the initial presentation for COVID-19 for most of the cases.
Table 1: Demographic characteristic, inflammatory markers and outcome.

Conclusion
Our observational retrospective case series reinforces the need to watch for new onset DM and monitor blood sugar closely in those with known diabetes mellitus during SARS-CoV-2 infection, in order to avoid such serious complications as DKA and HHS.

Disclosures
Jihad Slim, MD, Abbvie (Speaker’s Bureau)Gilead (Speaker’s Bureau)Jansen (Speaker’s Bureau)Merck (Speaker’s Bureau)ViiV (Speaker’s Bureau)
69. Effective Contact Tracing Strategies for COVID-19: A Municipal Health Department’s Model
Authors: Persaud Paul , Suh Jin S , Bond Kate , Espinal-Mesa Alicia , Suh Bennett 
Published: January 2021

Abstract

Background
During the COVID-19 pandemic, contact tracing program as part of a larger epidemiological case investigation was effectively implemented by the local department of health in Paterson, NJ. The Paterson Communicable Disease Strike Team (PCDST) was established by leveraging skills and using existing public health staff of the health department team which led to a timely and robust public health intervention.

Methods
PCDST comprised of 25 communicable disease investigators/contact tracers established in preparation for public health response in the event of large-scale communicable disease outbreaks pre-COVID. In March 2020 with initial COVID-19 cases in Paterson, PCDST was activated utilizing NJ DOH’s Communicable Disease Reporting and Surveillance System (CDRSS). Additional staff members were cross-trained to augment team as new cases surged. A triage coordinator would identify and assign new cases to disease investigators at a 24/7 schedule. Disease Investigators would provide test results, perform epidemiological case interviews, elicit close contacts, and provide isolation/quarantine recommendations. Case-contact monitors followed up daily basis until completion of isolation/quarantine period.

Results
As of June 15, 2020, 6537 cases tested COVID-19 (+) in Paterson, NJ. 91% of cases and their contacts were interviewed. Peak occurred in mid-April with 263 cases on a single day. By mid-June, daily number of cases declined to 7/day. Reported COVID-19 mortality rate in Paterson (4.65%), compared to surrounding towns in the same county of Passaic (6%), other large cities in New Jersey (Newark 8%, Jersey City 7.4%) and New Jersey state (7.59%).

Conclusion
Despite limited resources, we were able to cross train and engage our frontline public health team (PCDST) to investigate and effectively contact trace new COVID-19 cases to help contain spread of infection. Although its unclear if our intervention impacted mortality rates, it is certain that contact tracing using a trained public health workforce is a model that has proven successful in Paterson. A local public health workforce vested in their communities can develop rapport needed to build trust and confidence in an intervention that elicits confidential medical information to limit viral transmission.

Disclosures
All Authors: No reported disclosures
84. Clarifying the Congenital Zika Syndrome Phenotype and Expanding to Congenital Zika Spectrum in the Absence of Laboratory Evidence
Authors: Zambrano Laura D , Delaney Augustina , Rose Charles E , Gilboa Suzanne , Tong Van , Valencia-Prado Miguel , Roth Nicole , Cragan Janet , Moore Jazmyn , Staples J Erin , Honein Margaret , Moore Cynthia 
Published: January 2021

Abstract

Background
Congenital Zika syndrome (CZS) is a term used to describe the pattern of anomalies in infants due to congenital Zika virus (ZIKV) infection. To date, published reports of infants with these anomalies have been primarily small case series of the most severely affected infants and attempts to determine the CZS phenotype have been based on those reports. Lack of a standard definition has led to inconsistencies in the term’s use in the literature and uncertainty about the full spectrum of anomalies, limiting the application for diagnostic and surveillance purposes.
Cluster analysis of brain and eye anomalies associated with congenital Zika infection. Clustering occurred independent of laboratory evidence of Zika virus infection, yielding a clinically distinct phenotype associated with congenital infection.

Methods
We sought to understand which defects co-occur with possible congenital ZIKV infection using data from 415 mother-infant dyads with laboratory evidence of confirmed or presumptive Zika virus infection from the U.S. Zika Pregnancy and Infant Registry, and a comparison group of 4534 mother-infant dyads with no documented or plausible ZIKV infection from the Zika Birth Defects Surveillance System. We use k-means cluster analysis, discriminant analysis, and regression approaches to identify combinations of defects consistent with possible congenital ZIKV infection.

Results
A clinically distinct phenotype emerged as a single cluster in infants for whom both brain and eye defects were recorded that corresponded to evidence of confirmed or probable ZIKV infection. A combination of six defects (sub-cortical calcifications, chorioretinal atrophy/pigmentary anomalies, arthrogryposis or clubfoot, cerebral atrophy or ventriculomegaly, abnormal cortical gyration, and optic nerve atrophy/pallor/other optic nerve abnormalities) predicted the presence of laboratory evidence (area under the receiver operating characteristics curve: 0.95, 95% confidence interval: 0.90–0.99).

Conclusion
Further analyses are underway to develop a scoring rubric to weigh evidence of specific congenital anomalies, separately and in combination, that are consistent with laboratory evidence of congenital ZIKV infection. A quantitatively determined spectrum of Zika-associated anomalies, based on the presence of specific combinations of congenital anomalies, will inform a clinical decision tool to improve patient counseling and public health surveillance practices.

Disclosures
All Authors: No reported disclosures
88. Impact of a Computerized Clinical Decision Support Tool on clostridioides Difficile Testing and Oral Vancomycin Utilization as a Balancing Metric
Authors: Hussain Cory , Aragon Deborah , Knepper Bryan C , Jenkins Timothy C , Shihadeh Katherine C , Young Heather 
Published: January 2021

Abstract

Background
Over diagnosis of hospital-onset Clostridioides difficile infection (HO-CDI) is directly tied to inappropriate C. difficile testing which does not distinguish between infected or colonized individuals. This can lead to inappropriate therapy. Multiple studies have utilized Computerized Clinical Decision Support (CCDS) tools to reduce inappropriate C. difficile testing. Our study looks at the impact of a Self-Assessment CCDS tools on C. difficile testing for HO-CDI and oral vancomycin utilization as a balancing metric.

Methods
Our institution utilizes a two-step test to diagnose HO-CDI that consists of toxin A/B enzyme immunoassay followed by a confirmatory PCR. We applied a self-assessment driven CCDS approach to reduce testing for HO-CDI. Our intervention was deployed in the 3rd quarter of 2018. It asked 3 questions about stool frequency, laxative use and previous C. difficile testing in the order itself. Inappropriate indications for testing included any of the following: &lt; 3 bowel movements within 24 hours, receipt of a laxative within the past 48 hours, or a previous C. difficile test within the previous 7 days. Ordering providers would self-answer these questions. A ‘yes’ response to any of the three questions prevented further test ordering; though respondents had the freedom to change the answer and still proceed with the test order. We evaluated 3 metrics that were all calculated per 1000 inpatient census days: oral vancomycin usage, HO-CDI rates and C. difficile testing rates.

Results
Compared to baseline, our intervention resulted in a significant reduction of C. difficile testing and HO-CDI rates (Figure 1, Table 1). Oral vancomycin usage also decreased significantly (Figure 2, Table 1).
Figure 1. C. difficile testing and Hospital Onset C. difficile Infection Rates by Month, Before and After Intervention

Figure 2. Oral Vancomycin Utilization by Month, Before and After Intervention

Table 1. Changes in Median Rates of C. difficile testing, Hospital Onset C. difficile Infections and Vancomycin Utilization, Before and After Intervention.

Conclusion
Our self-assessment driven CCDS-based diagnostic stewardship resulted in a significant reduction in inappropriate C. difficile testing for HO-CDI and HO-CDI rates. Oral vancomycin utilization as a balancing metric also decreased significantly. This was despite the use of a self-assessment driven approach with the freedom to change the answers in order to proceed with the test order.

Disclosures
All Authors: No reported disclosures
97. Assessment of Personal Protective Equipment Adherence in Red Box Using Remote Video Auditing
Authors: Singh Vansha , Khatri Akshay , Khameraj Aradhana , Rasul Rehana , Schwartz Rebecca , Malhotra Prashant , Farber Bruce 
Published: January 2021

Abstract

Background
“Red box (RB)” is a delineated space in the entry way to a patient(pt) room(rm) that facilitates communication between pt and health care provider (HCP) without the latter needing to don/doff personal protective equipment (PPE). It decreases PPE use where unnecessary and increases pt satisfaction ratings. Remote Video Auditing (RVA) is a novel technique used to ensure adherence to isolation precautions. In this study, we used RVA to compare HCP compliance rates with PPE use in isolation rms with or without RB.

Methods
A prospective observational study (2/26/19-2/27/20) was designed to evaluate HCP compliance with PPE when entering or exiting droplet/contact isolation rms. RB was demarcated by red tape as a 3-ft area at rm entrance, &gt;6 ft from the head of the bed. Cameras were placed at the entry of 4 rms with RB (RB rms) and 2 isolation rms without RB (control rms). Adherence to gowns, gloves, masks and hand hygiene (HH) was reviewed by trained independent remote observers to maintain uniformity. When HCPs stayed in the RB, compliance at exit was calculated. Compliance was compared between events of HCPs going beyond the RB and those of HCPs entering/exiting control rms using binomial regression models with log link.

Results
RVA captured 6959 pt encounters in 6 rms over a year. Consistent with RB protocol, when HCPs utilized the RB, 69.9% did not practice HH, 91.6% did not utilize gloves and 95.2% did not use gowns (Table 1). When HCPs went beyond the RB, there was significantly increased non-compliance with PPE and HH in RB rms compared with control rms (Table 2). Healthcare-associated infection (HAI) rates for this unit assessed using NHSN criteria demonstrated no increase as compared to prior years.
Table 1: Non-Compliance among those who entered Red Box but did not go into the room fully

Table 2: Comparison of non-compliance between group that went beyond Red Box Vs. Control group without Red Box

Conclusion
RVA, a novel, labor-efficient and objective method, was used for observing and comparing PPE compliance in RB rms. Consistent with the purpose of RB, &gt;90% HCPs did not use PPE while confined within it. However, HCPs going beyond the RB were more non-compliant with PPE use as compared to HCPs in control rms. While HAI rates were not increased, this finding is concerning – HCPs going beyond RB may not have used PPE (even in close proximity) due to a false sense of security due to RB. Re-education about optimal use of the RB or discontinuing RB should be considered.

Disclosures
All Authors: No reported disclosures