Initial Study Period Research Articles

Intervention at an early threshold for post-hemorrhagic ventricular dilatation in preterm infants: a systematic review and meta-analysis.

Very few adequately powered studies exploring early thresholds for intervention in the management of post-hemorrhagic ventricular dilatation (PHVD) in preterm infants have identified consistent neurodevelopmental advantages at 12-30months. We aimed to conduct a meta-analysis on the efficacy and safety of early versus conservative thresholds for intervention, primarily aimed at normalizing cerebrospinal fluid (CSF) pressure, in the management of PHVD in preterm infants. Multiple databases were searched for eligible papers, and prospective randomized trials involving preterm infants were selected. The results are expressed as relative risks (RRs) with 95% confidence intervals (CIs). The main outcome was survival without moderate-to-severe neurodevelopmental impairment at 12-30months. Ten articles representing seven randomized trials comparing early versus conservative thresholds for interventions were included. Five trials (n = 545 infants) reported no difference in the main outcome between early and conservative groups [RR 0.99 (0.71, 1.37)]. Sensitivity analysis excluding data from a medication trial did not alter the main outcome [RR 1.15 (0.95, 1.39)]. Infants in the early threshold group received significantly more interventions [RR 1.48 (1.05, 2.09)]. Deaths before discharge/during the initial study period [RR 1.04 (0.70, 1.54)] or a composite of death or shunt insertion [RR 1.04 (0.86, 1.27)] were comparable between the two groups. Early intervention for PHVD, before a clinical or ultrasound threshold is met, leads to additional clinical procedures but does not improve survival without moderate-severe neurodevelopmental impairment at 12-30months. Caution should be exercised in interpreting these results due to significant variation between the studies. Supplementary file 3 (MP4 131172kb).

645 Time to Cholecystectomy for Gallstone Pancreatitis

Abstract Aim AUGIS 2016 guidelines state that patients with mild gallstone pancreatitis should undergo a cholecystectomy within the same admission or if discharged within two weeks of presentation. This reduces readmission and leads to shorter hospital stays. In 2020, compliance at Poole hospital was 57%. This audit aimed to identity current compliance and opportunities for improvement. Method Retrospective study of patients admitted at Poole Hospital from 01/12/22 to 31/05/23. This was followed by presentation of findings and discussion at staff meeting and staff education and re-audited from 10/07/23 to 10/11/23. Results 29 patients with gallstone pancreatitis were admitted during the initial study period. 22 fit for surgery, 2 patients passed away and 5 were unfit for surgery. 9 had cholecystectomy within 2 weeks giving a guideline compliance of 41%. Median hospital stay overall was three days. Median wait time to cholecystectomy was 5.5 days. Three patients who did not have a cholecystectomy within 2 weeks were later readmitted with pancreatitis. Five patients had previously been admitted with gallstone related diseases. The main barrier to compliance identified was a lack of regular theatre slots for cholecystectomy leading to regular cancellation on CEPOD. The later re-audit showed a compliance of 32%. Conclusions Compliance with AUGIS guidelines has fallen since 2020. Unfortunately, staff education and presentation of findings failed to improve compliance and a high rate of readmission wastes resources. To improve, service configuration is needed with dedicated theatre slots, this should be considered for the planned Poole and Bournemouth general surgery department mergers.

#1884 Slowing kidney disease with weight loss: a randomised controlled feasibility study (SLOW-CKD Feasibility Study)

Abstract Background and Aims Obesity is a modifiable risk factor for chronic kidney (CKD) and progression to kidney failure. Low energy diets (LEDs) (800 to 1000 kcal/day) are an established weight management strategy and have demonstrated the ability to facilitate 10 to 15 kg weight loss and induce diabetes remission. However, the use of LEDs in adults with CKD is limited and there have been no randomised controlled trials (RCT) exploring their use. Before initiating a definitive trial, there is first a need to assess feasibility and safety. The primary aim of this study was to test the feasibility, acceptability and safety of a low energy diet and weight management program in individuals with obesity and CKD. Method The SLOW-CKD Feasibility Study, a 6-month multi-centre RCT in kidney outpatient clinics in Brisbane Australia, targeted adults with stages 1-3 CKD and a body mass index (BMI) ≥ 30 kg m2 with proteinuria (urinary albumin to creatinine ratio >3 mg/mmol). Participants wererandomised (1:1). The LED group followed a 3-month LED (800-1000 kcal/day) with meal replacements and low-calorie foods, with fortnightly dietitian support. Following this, participants entered a 3-month weight maintenance phase,emphasising healthy eating and commencing a physical activity program guided by an exercise physiologist. The usual care group was offered weight loss support through the kidney clinic, involving referral to a dietitian or weight loss program if agreeable. Primary outcomes included safety (study related serious adverse events [SAEs] and adverse events [aEs]) and feasibility (recruitment rate, retention rate, target weight loss). Secondary outcomes explored changes in anthropometry and clinical measures, patient-reported outcomes, and participant experiences through semi-structured interviews. Pre-defined safety and feasibility outcome criteria are presented in Table 1. Results Overall, 49 participants consented to participate (mean age 52.4 ± 3.8 years, 57% male). The incidence of SAEs was low and comparable between the two groups. There were two SAEs in the LED group (hypoglycaemia and acute kidney injury both requiring hospital admission) and one in the control (hypoglycaemia requiring hospital admission). The most common AE was hyperkalaemia with three episodes (>6.0 mmol/L) in each group. Two of the three feasibility criteria were met deeming the intervention feasible—see Table 1. Mean weight loss for the initial 3-month study period was 10.6 kg ± 5.1 kg in the LED group and 0.7 kg ± 4.3 for the usual care group (p = <0.00). Conclusion Our findings provide important preliminary evidence that LEDs are relatively safe, feasible, and demonstrate promising efficacy as a treatment option for obesity in adults with CKD. A definitive RCT exploring the use of LEDs to improve clinical outcomes and slow progression of CKD is warranted.

E054 Rituximab dose minimisation in rheumatoid arthritis, a retrospective outcome analysis

Abstract Background/Aims Rituximab was originally developed as a non-Hodgkin lymphoma treatment and rheumatology adopted the same dosing for rheumatoid arthritis(RA); two 1000mg doses two weeks apart for each maintenance cycle. UHSussex utilises self-referral for maintenance rituximab dosing once disease control lessens. Evidence demonstrates patients treated with lower dose rituximab still enjoy good disease control with less immunosuppression, reduced hospital attendance and reduction in drug expenditure. Following one two-dose cycle, stable RA patients were prescribed a single 1000mg dose from 2020 onwards. A retrospective outcome analysis was completed in August 2022; however, results were highly impacted by Covid-19 and a repeat analysis was required. Aim: to assess impact of a single 1000mg dose rituximab regime on patient sustained outcomes, dose intervals, Disease Activity Scores (DAS) and drug expenditure. Methods The pharmacy database was used to identify RA patients receiving rituximab from March 2020 to August 2023. Patients received at least one standard two-dose cycle before switching to a single infusion. Patients were excluded if lost to follow up (under care of rheumatology for less than a year following dose switching) or considered clinically unstable. Patient letters and departmental records were accessed for disease scores and treatment intervals. Results Table1: Results from the two analysis periods From the original cohort (31/59)53% remained on single dosing. Switch back tended to occur within 18 months of switching. DAS scores were not collected reliably and were omitted. Conclusion Covid-19 impacted services and attitudes during the initial study period. Many patients stopped treatment, particularly rituximab, due to the prolonged duration of effect, excluding them from analysis. The dose-interval increase during the first analysis was considered a result of the pandemic. Patients and clinicians delayed infusions; minimising immunosuppression due to perceived increased risk of Covid-19. The continued interval increase in the second analysis may identify a patient cohort in deep remission eligible for therapy review. The study highlights poor practice in collecting and recording DAS scores and appropriate patient-clinician interaction opportunities. 53% of patients remained on single infusions in August 2023 resulting in resource savings, reduced hospital attendance, immunosuppression and significant cost savings demonstrating the rationale for this option. Disclosure S. Butler: Honoraria; Abbvie, Janssen. H. Smith: Honoraria; Novartis, Abbvie.

Land-based investment implications on land use land cover change and livelihood of the local community in Northern Amhara Region, Ethiopia

A surge in land-based investment has been taking place in developing countries, including Ethiopia, with the aim to foster economic growth, enhance food security, and reduce poverty. This study sought to investigate the impact of such investments in the western Armachiho district of the Amhara Regional State, Ethiopia, using remote sensing data from 1995, 2010, and 2020 supplemented by socioeconomic surveys and field observation to validate the spatial data. The results revealed significant land use and land cover changes in the district over the past twenty-five years. Forest cover decreased from 60.92% in 1995 to 27.6% in 2010, while water bodies, including rivers, streams, and ponds, declined from 3.04% to 1.4% during the same period. Conversely, built-up areas, bush land, farmland, and bare land exhibited an increasing trend. The observed changes during the initial study period can be attributed to the expansion of land-based investments and illegal farmland encroachment in the area under investigation. The results further indicated that the expansion of such investments during this period had adverse effects on the local community, resulting in the loss of access to farmland, grazing land, and forest products that served as sources of income. The results also demonstrated that the delineation of agricultural investment land, the closure of unproductive land, and the issuance of land-holding certificates have prevented illegal encroachment that contributed to the improvements in forestland cover between 2010 and 2020. Hence, when granting significant amounts of land for land-based investment, it is crucial to consider not only the short-term economic benefits but also the well-being of local communities and the principles of environmental sustainability.

Use of IV Hydration Instead of Exchange Transfusion for Prophylactic Management of Pain Crisis in Homozygous (SS) Sickle Cell Disease Helps Maintain Hgb Levels and Prevents Further Escalation of Iron Overload

Introduction: Indications for exchange transfusion in the management of sickle cell disease and its complications are over time becoming limited. Currently accepted indications include acute chest syndrome and cerebrovascular accidents only. However, there is often consideration of using exchange transfusions for management of sickle cell pain crisis episodes resistant to opioid-based pain management. This is, however, of questionable efficacy due to concerns of iron overload as well as alloimmunization. The excessive utilization of blood products also presents a significant challenge. Therefore, it is important to explore alternatives to exchange transfusion in the management of pain crisis in sickle cell disease. Method: This study aimed at investigating the effects of transitioning patients with homozygous SS disease from routine exchange transfusions to IV hydration protocols. The main objective was to examine the changes in Hgb levels and the status of iron overload in these patients. A cohort of 16 patients with a Ferritin level above 1000 ng/ml, who were already receiving regular exchange transfusions, were included in the study. Their Hgb levels and Ferritin levels were measured periodically. This group was then given IV hydration twice a week, regardless of whether they were experiencing pain issues. We then compared the Hgb and Ferritin levels during a 6-month period of active exchange transfusions and 6-month period of being on IV hydration protocols. Both periods were a year apart, allowing for adequate homeostatic changes to take place. Additionally, we compared the number of simple transfusions during both these periods. Result: The mean ferritin level in patients getting exchange transfusions was 6097 ng/mL with the mean Hgb level maintained at 7.48 g/dL. During the initial study period, there were 14 exchange transfusion sessions involving 96 units of packed red blood cells (PRBCs). Additionally, 8 units of simple transfusion units were administered during the same period. Interestingly, as this cohort transitioned away from exchange transfusions, the number of simple transfusions increased to 30. Only one exchange transfusion occurred during the second 6-month observation period. During this time, ferritin level stopped increasing, and the mean was measured at 6076 ng/ml. The Hgb levels did show a slight decrease, with the mean being 6.90 g/dL, but the difference was not statistically significant. Conclusion: The findings of this study suggest that the use of IV hydration protocol is effective in managing iron overload issues and maintaining an adequate Hgb level in patients who were previously undergoing routine exchange transfusions to prevent or manage pain crisis episodes. The results indicate that IV hydration should be initiated when ferritin levels increase beyond 1000 ng/ml, rather than waiting for more advanced stages. Moreover, the study shows that even when IV hydration is started at a later stage of iron overload, it still appears to limit further iron accumulation, as evidenced by the stabilization of ferritin levels. Overall, the use of IV hydration as an alternative to routine exchange transfusions holds promise in managing pain crisis and iron overload in sickle cell disease.

The effectiveness of the use of mastitis vaccine in breeding farms

The article presents data showing the effectiveness of the use of anti-mastitis vaccine in breeding farms of the Sverdlovsk region, based on the study of the level of diagnosed mastitis and the indicator of somatic cells in milk. Studies have shown that the use of animal immunization against mastitis has a positive effect, so 6 months after the first vaccination of animals in the breeding reproducer and plant, the number of detected mastitis decreased by 16,6% and 7,3%, respectively, and the level of somatic cells in the milk of highly productive cows by 26,5% and 10,7%, respectively. 12 months after the first vaccination scheme was applied, the total number of animals with signs of mastitis in the breeding reproducer and plant was 13,3% and 7,5%, respectively. The level of somatic cells in the nucleus amounted to 290 thousand. /ml., and the stud farm of 450 thousand/ml 24 months after first use of vaccination schemes, the level of mastitis was identified at 6,0% and 5,7% of the studied population of high yielding cows breeding farm and breeding farm, respectively. The average number of somatic cells found in milk of animals of a farm decreased by 80 thousand/ml, the farm – to 79 thousand/ml, in comparison with the previous study period. The study revealed a significant decrease in diagnosed mastitis in animals after 32 months due to the use of the STARTVAK antimastitic vaccine, the total number of diseases in the breeding reproducer decreased by 30,6% compared to the period of the beginning of vaccination, and in the breeding plant – by 26,2%. As a result, the dynamics of reduction of subclinical and clinical mastitis in the breeder compared to the period at the time of immunization was 19,5% and 11,1%, respectively. And in the stud farm, the level of subclinical and clinical mastitis decreased by 16,9% and 9,0%, respectively. The number of somatic cells in the milk of cows contained in the breeding reproducer was 152 thousand/ml, which is 83,9% lower compared to the initial study period. The level of somatic cells in the studied samples of milk of animals kept in the breeding plant was 263 thousand/ml, which is 62,2% lower than this indicator before the application of the animal vaccination program against mastitis.

Serial prophylactic exchange blood transfusion in pregnant women with sickle cell disease (TAPS-2): statistical and qualitative analysis plan for a randomised controlled feasibility trial

BackgroundThere are significant knowledge gaps regarding the effectiveness of serial prophylactic exchange blood transfusion (SPEBT) for pregnant women with sickle cell disease (SCD). The protocol for the randomised feasibility trial assessing SPEBT versus usual care in women with SCD (TAPS2 trial) has previously been published. This publication outlines the statistical and qualitative analysis plan for the study.Methods and designTAPS2 is a randomised two-arm phase 2 feasibility trial with a nested qualitative study and health economic evaluation. Up to 50 pregnant women with SCD and a singleton pregnancy will be recruited and individually randomised to either SPEBT approximately every 6–10 weeks until delivery (intervention arm) or to usual care (control arm). Information will be collected on a range of feasibility and clinical outcomes.ResultsDue to the impact of COVID-19 on study recruitment, the initial study period of 24 months was extended to 48 months. Other protocol updates designed to mitigate the impact of COVID-19-related disruption included allowing for remote consent and conducting all qualitative interviews by telephone. The primary outcome for the trial is the overall recruitment rate. The number of women screened, eligible, consented, randomised and withdrawn will be summarised as a CONSORT flow diagram. Differences in clinical outcomes will additionally be presented as an initial assessment of efficacy and to inform sample size calculations for a future definitive trial. Qualitative interviews with trial participants and clinicians will be analysed using reflexive thematic analysis; data from interviews with participants who declined to participate in the trial will be extracted and incorporated into summary tables to report key findings. The health economic analysis plan is not covered by this update.ConclusionThe publication of this analysis plan is designed to aid transparency and to reduce the potential for reporting bias.Trial registrationNIH registry (www.clinicaltrials.gov), registration number NCT03975894 (registered 05/06/19); ISRCTN (www.isrctn.com), registration number ISRCTN52684446 (retrospectively registered 02/08/19).

Active surveillance testing to reduce transmission of carbapenem-resistant, gram-negative bacteria in intensive care units: a pragmatic, randomized cross-over trial

BackgroundIn intensive care unit (ICU) settings, the transmission risk of carbapenem-resistant, gram-negative bacteria (CRGNB) is high. There is a paucity of data regarding the effectiveness of interventions, including active screening, preemptive isolation, and contact precautions, to reduce transmission of CRGNB.MethodsWe conducted a pragmatic, cluster-randomized, non-blinded cross-over study in 6 adult ICUs in a tertiary care center in Seoul, South Korea. ICUs were randomly assigned to perform active surveillance testing with preemptive isolation and contact precautions (intervention) or standard precautions (control) during the initial 6-month study period, followed by a 1-month washout period. During a subsequent 6-month period, departments that used standard precautions switched to using interventional precautions and vice versa. The incidence rates of CRGNB were compared between the two periods using Poisson regression analysis.ResultsDuring the study period, there were 2268 and 2224 ICU admissions during the intervention and control periods, respectively. Because a carbapenemase-producing Enterobacterales outbreak occurred in a surgical ICU (SICU), we excluded admissions to the SICU during both the intervention and control periods and performed a modified intention-to-treat (mITT) analysis. In mITT analysis, a total of 1314 patients were included. The acquisition rate of CRGNB was 1.75 cases per 1000 person-days during the intervention period versus 3.33 cases per 1000 person-days during the control period (IRR, 0.53 [95% confidence interval (CI) 0.23–1.11]; P = 0.07).ConclusionsAlthough this study was underpowered and showed borderline significance, active surveillance testing and preemptive isolation could be considered in settings with high baseline prevalence of CRGNB.Trial registration Clinicaltrials.gov Identifier: NCT03980197.

34574 Systemic medication treatment patterns in adults with atopic dermatitis (AD): Results from the European Prospective Observational Study in Patients Eligible for Systemic Therapy for Atopic Dermatitis (EUROSTAD)

Introduction: EUROSTAD (OBS14620) is an observational study of up to 60 months to characterize AD treatment in a real-world setting. Here, we describe systemic treatment-patterns in patients enrolled in EUROSTAD. Methods: Individuals with AD, ≥18 years old and eligible for systemic treatment, were enrolled. Initial study period was 18 months but was amended to 60 months. Treatment was prescribed by study investigators as per clinical practice. Follow-up population is defined as all patients who have completed ≥1 follow-up visit. Reported data is descriptive from the full-analysis set at 24 months. Results: 308 patients were enrolled (mean AD duration: 25.4 years). Most patients reported ≥1 systemic medication use at enrollment (92.5%). During follow-up (n = 295) most patients reported using either one (56.3%) or >1 (41.4%) systemic medication. Cyclosporin, dupilumab, corticosteroids and methotrexate were the most common systemic therapies. Most common reasons reported for treatment initiation were maintenance and exacerbation treatment (both 79.7%), while well-controlled disease (59.7%) and lack of efficacy (38.1%) were the most common reasons for discontinuation. Median duration of systemic treatment was between 1.1-13 months for the most common therapies (corticosteroids, 1.1 months (95% CI 1.0-1.5); cyclosporin, 5.4 months (4.2-6.6), methotrexate, 13.0 months [8.9-16.9]); median duration of dupilumab treatment was not reached because >50% of patients were still on dupilumab at 24 months. Conclusion: AD therapy was started for exacerbation or maintenance treatment and discontinued mainly due to lack of efficacy or well-controlled disease. Patients who initiated dupilumab were more likely to remain on dupilumab compared with other systemic therapies.

ESBL plasmids in Klebsiella pneumoniae: diversity, transmission and contribution to infection burden in the hospital setting

BackgroundResistance to third-generation cephalosporins, often mediated by extended-spectrum beta-lactamases (ESBLs), is a considerable issue in hospital-associated infections as few drugs remain for treatment. ESBL genes are often located on large plasmids that transfer horizontally between strains and species of Enterobacteriaceae and frequently confer resistance to additional drug classes. Whilst plasmid transmission is recognised to occur in the hospital setting, the frequency and impact of plasmid transmission on infection burden, compared to ESBL + strain transmission, is not well understood.MethodsWe sequenced the genomes of clinical and carriage isolates of Klebsiella pneumoniae species complex from a year-long hospital surveillance study to investigate ESBL burden and plasmid transmission in an Australian hospital. Long-term persistence of a key transmitted ESBL + plasmid was investigated via sequencing of ceftriaxone-resistant isolates during 4 years of follow-up, beginning 3 years after the initial study.ResultsWe found 25 distinct ESBL plasmids. We identified one plasmid, which we called Plasmid A, that carried blaCTX-M-15 in an IncF backbone similar to pKPN-307. Plasmid A was transmitted at least four times into different Klebsiella species/lineages and was responsible for half of all ESBL episodes during the initial 1-year study period. Three of the Plasmid A-positive strains persisted locally 3–6 years later, and Plasmid A was detected in two additional strain backgrounds. Overall Plasmid A accounted for 21% of ESBL + infections in the follow-up period.ConclusionsHere, we systematically surveyed ESBL strain and plasmid transmission over 1 year in a single hospital network. Whilst ESBL plasmid transmission events were rare in this setting, they had a significant and sustained impact on the burden of ceftriaxone-resistant and multidrug-resistant infections. If onward transmission of Plasmid A-carrying strains could have been prevented, this may have reduced the number of opportunities for Plasmid A to transmit and create novel ESBL + strains, as well as reducing overall ESBL infection burden.

Surgical wait times and socioeconomic status in a public healthcare system: a retrospective analysis

BackgroundOne aim of publicly-funded health care systems is to provide equitable access to care irrespective of ability to pay. At the same time, differences in socioeconomic status (SES) are associated with health outcomes and access to care, including waiting times for surgery. In public systems where both high- and low-SES patients use the same resources, low-SES patients may be adversely impacted in surgical waiting times. The purpose of this study was to determine whether a publicly-funded health system can provide equitable access to surgical care across socioeconomic status.MethodsPatient-level records were obtained from a comprehensive provincially-administered surgical wait time database, encompassing years 2006–2015 and 98% of Ontario hospitals. Patient SES was determined by linking postal code with the Material and Social Deprivation Index. Surgical waiting times (time in days between decision to treat and surgery) accounted for patient-initiated delays in treatment, and regression analysis considered age, SES, rurality, sex, priority level for surgical urgency (assigned by surgeons), surgical subspecialty, number of visits, and procedure year.ResultsFor the 4,253,305 surgical episodes, the mean wait time was 62.3 (SD 75.4) days. Repeated measures least squares regression analysis showed the least deprived SES quintile waited 3 days longer than the most deprived quintile. Wait times dropped in the initial study period but then increased. The proportion of procedures exceeding wait time access targets remained low at 11–13%.ConclusionsThe least deprived SES quintile waited the longest, although the absolute difference was small. This study demonstrates that publicly-funded healthcare systems can provide equitable access to surgical care across SES.

Formation of an inclusive culture in an educational organization

Introduction. The formation relevance of an inclusive culture in an educational organization is due to the need to resolve the contradiction between the society need to ensure equal rights to education for various population categories and insufficiently systematized knowledge about the model diversity for applying an integrated approach in the implementation of both formalized and meaningful measures to increase the educational environment accessibility for students with disabilities and various educational needs. The technical arrangement of educational organization external and internal territories, despite the rapid implementation, without taking into account the building structure features, the aperture dimension, including in buildings that classified as old buildings, does not lead to the establishment of a full-fledged accessible environment, as well as the implementation of the adaptive program without teaching staff appropriate professional training and professional education. In this regard, the formation of an educational organization inclusive culture as a complex of substantive and technological measures, implemented consistently and step by step, seems to be one of the most important areas of its operations. Materials and methods. In the course of the study, the educational inclusion understanding by participants in the educational process in the higher education organization, the specifics of the formed organization atmosphere in the educational inclusion adoption, the teaching staff readiness level for its implementation was studied. Analysis methods, content analysis, questionnaires, interviews, conversations, and observation were used. Research results. The system-forming working principle with students of the initial study period at the university was formulated, factors and indicators of an organization positively oriented atmosphere were identified, in-demand interactions types among the participants in the educational process were established, including in the conditions of technical flaws in the accessible environment organization. Discussion and conclusion. The practical significance of the study results lies in their use in the educational organization work, in their application possibility in the programs of teaching staff professional training and professional education. The research prospects are to reveal the adapted program's components potential, their coordination with the technical educational environment modernization, and to identify the dynamics of the developmental effects in students with special educational needs.

Linking health service utilisation and mortality data-unravelling what happens after fall-related paramedic care.

A randomised controlled trial implemented and evaluated a new model of care for non-transported older fallers to prevent future falls and unplanned health service use. This current study uses linked data to evaluate the effects of the intervention beyond the initial 12-month study period. Study data from an established cohort of 221 adults were linked to administrative data from NSW Ambulance, Emergency Department Data Collection, Admitted Patient Data Collection and Registry of Births, Deaths and Marriages evaluating health service use at 12, 24 and 36months following randomisation including time to event (health service utilisation) and mortality. Negative binomial and Cox's proportional hazard regression were performed to capture the impact of the study between groups and adherence status. At 36months follow-up, 89% of participants called an ambulance, 87% attended the Emergency Department and 91% were admitted to hospital. There were no significant differences in all-cause health service utilisation between the control and intervention group (IG) at 12, 24 and 36months follow-up. Fall-related health service use was significantly higher within the IG at 12 (IRR:1.40 (95%CI:1.01-1.94) and 24months (IRR:1.43 (95%CI:1.05-1.95)). Medication use, impaired balance and previous falls were associated with subsequent health service use. Over 40% of participants died by the follow-up period with risk of death lower in the IG at 36months (HR:0.64, 95%CI:0.45-0.91). Non-transported fallers have a high risk of future health service use for fall and other medical-related reasons. Interventions which address this risk need to be further explored.

968. Leveraging On-Demand Digital Education to Increase ID Specialists’ Knowledge and Confidence on Appropriate Probiotic Use for CDI Prevention

BackgroundProbiotics are increasingly being used in healthcare. As the number of probiotic options and their potential uses increase, it has become more challenging to make an informed selection for a given disease state. This study assessed the ability of digital education to improve Infectious Disease (ID) specialists’ knowledge regarding the use of probiotics in preventing Clostridioides difficile infection (CDI) and antibiotic-associated diarrhea (AAD). MethodsA CME/ABIM MOC certified, educational program featuring a panel of 3 expert ID faculty was developed. The program sought to clarify the role of different probiotic strains in the prevention or treatment of different disease states. 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 < 0.05 are statistically significant. Effect sizes were evaluated using Cramer’s V (< 0.05 modest; 0.06-0.15 noticeable effect; 0.16-0.26 considerable effect; > 0.26 extensive effect). The activity launched on a website dedicated to continuous professional development. Data for this matched-learner analysis were collected through 09/09/20.ResultsTo date, 7122 HCPs, including 5068 physicians, have participated in the activity. Data from the subset of ID specialists (n=235) 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 ID specialists who answered assessment questions correctly (47% pre vs 69% post; P < .0001; V=.22). Improvements were also observed in several specific areas of assessment (Table) and confidence in their ability to select a probiotic-based on strain- and disease-specific efficacy (36% increase). ConclusionParticipation in this online educational program significantly improved ID specialists’ understanding of the interplay between strain- and disease-specificity in the context of probiotics. These findings highlight the potential for well-designed online education to positively impact physicians’ knowledge and confidence Disclosures All Authors: No reported disclosures

Association Between Prenatal Exposure to Metals and Atopic Dermatitis Among Children Aged 4 Years in Taiwan

The prevalence of atopic dermatitis has substantially increased in recent decades, and atopic dermatitis could lead to allergic airway inflammation later in life. A previous study found that inorganic arsenic exposure was associated with allergic airway inflammation in children aged 8 to 14 years. However, the association between prenatal exposure to arsenic and other metals and the risk of atopic dermatitis among young children remains unknown. To assess the association between prenatal exposure to arsenic and other metals and the occurrence of atopic dermatitis in children at age 4 years. In total, 1152 pregnant women were enrolled in the original Taiwan Maternal and Infant Cohort Study (TMICS), a multicenter birth cohort study conducted at 9 hospitals in northern, central, southern, and eastern Taiwan from October 2012 to May 2015. Of those, 586 mothers and children aged 4 years participated in follow-up questionnaire interviews from August 2016 to January 2019. After excluding 216 participants with missing data, the final statistical analysis of follow-up data included 370 mother and child pairs from the central and eastern regions of Taiwan. Data were analyzed from February 2 to August 12, 2021. Arsenic, cadmium, lead, cobalt, copper, nickel, thallium, and zinc during pregnancy. The outcome was parent-reported atopic dermatitis history among children aged 4 years. The presence of atopic dermatitis was defined as a positive response to the question, "Has your child ever had atopic dermatitis diagnosed by a physician?" During the initial TMICS study period, concentrations of arsenic, cadmium, lead, cobalt, copper, nickel, thallium, and zinc were measured in maternal urine during the third trimester of pregnancy using an inductively coupled plasma mass spectrometer. Estimated total inorganic arsenic exposure was calculated using a model that included data on both total arsenic and arsenic species (arsenite, arsenate, monomethylarsonate, and dimethylarsenate) obtained from a previous TMICS cohort. Among 370 children included in the analysis, the mean (SD) age was 3.94 (0.59) years; 208 children (56.2%) were male, and 267 children (72.2%) were from the central region of Taiwan. A total of 110 children (29.7%) had atopic dermatitis at age 4 years. Maternal estimated total inorganic arsenic exposure during pregnancy was associated with increased odds of atopic dermatitis among children at age 4 years (odds ratio [OR], 2.42 [95% CI, 1.33-4.39] for every doubled increase of total inorganic arsenic) after adjusting for parental allergies, child's sex, geographic area, maternal educational level, and exposure to tobacco smoke. Every increased unit in the weighted quantile sum index of maternal metal exposure was significantly associated with atopic dermatitis (OR, 1.63; 95% CI, 1.28-2.07). Arsenic (40.1%) and cadmium (20.5%) accounted for most of the metal mixture index. This cohort study found that prenatal exposure to inorganic arsenic and coexposure to inorganic arsenic and cadmium were associated with a higher risk of atopic dermatitis in young children. These findings suggest that prevention of exposure to inorganic arsenic and cadmium during pregnancy may be helpful for the control of atopic dermatitis and other potential allergies in children.

Improving preprocedure antithrombotic management: Implementation and sustainment of a best practice alert and pharmacist referral process

BackgroundElectronic medical record–based interventions such as best practice alerts, or reminders, have been proposed to improve evidence‐based medication prescribing. Formal implementation evaluation including long‐term sustainment are not commonly reported. Preprocedural medication management is often a complex issue for patients taking antithrombotic medications. MethodsWe implemented a best practice alert (BPA) that recommended referral to an anticoagulation clinic before outpatient elective gastrointestinal (GI) endoscopies. Eligible patients were taking an oral anticoagulant (warfarin or direct oral anticoagulant [DOAC]) and/or antiplatelet medications. Patients referred to the anticoagulation clinic were compared to those managed by the ordering provider. Outcomes assessed included guideline‐adherent drug management before endoscopy, documentation of a medication management plan, guideline‐adherent rates of bridging for high‐risk patients taking warfarin, and evaluation for sustained use of BPA. ResultsEighty percent of patients (553/691) were referred to the anticoagulation clinic during the initial 13‐month study period. Most referrals came from gastroenterologists (397/553; 71.8%) followed by primary care providers (127/554; 22.9%). Patients referred had improved rates of guideline‐adherent medication management compared to those who were not referred (97.4% vs 91.0%; P = .001). Documentation of medication plan was significantly higher in the referred group (99.1% vs 59.4%; P≤ .001). There were no differences in rates of appropriate bridging for patients taking warfarin. Implementation of the BPA also resulted in sustained, consistent use over an additional 18 months following the initial study period. ConclusionImplementation of a BPA before elective outpatient GI endoscopies was associated with improved rates of guideline‐adherent medication management and documented management plan, while streamlining preprocedural medication management.

Improving management of fever in neutropenic children with cancer across multiple sites.

To evaluate the effectiveness of a clinical pathway in achieving antibiotic administration in less than 60minutes for children with cancer, presenting with fever and neutropenia. Secondary objectives were to determine association between time to antibiotics (TTA) and other variables including fever duration, location of care and intravenous access types. Following introduction of the clinical pathway, we collected prospective data about management of all cases that did and did not use the pathway across multiple sites over 16months. A follow-up audit was conducted after 12months. We evaluated a total of 453 presentations. Use of the clinical pathway was significantly associated with achieving TTA in less than 60minutes (RR 0.69, 95% CI 0.56-0.85, p=<0.001). Despite varying use of the pathway over time, the median time to antibiotics was achieved in both the initial study period (57minutes) and sustained at follow-up (60minutes). TTA was also associated with types of intravenous access device and location of care and with length of stay. We did not find any association between TTA and any other variables. Clinical pathways improve fever management in this patient cohort. Ongoing education and auditing to identify factors which impact processes of care are necessary.

Upward trend in the frequency of community-acquired methicillin-resistant Staphylococcus aureus as a cause of pediatric skin and soft tissue infections over five years: a cross-sectional study.

The increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and its resistance to multiple antibiotics has become a serious challenge since the early 2000s. Especially, community-acquired MRSA (CA-MRSA) infections that appear mainly as skin and soft tissue infections (SSTIs) tend to increase worldwide. The objective of this cross-sectional study was to evaluate the trends in the frequency of SSTIs due to community-acquired S. aureus among children. All children with SSTIs caused by culture positive community-acquired S. aureus during the period from 2013 to 2018 were included in this study. Data of the outpatients were collected from medical records. Annual alteration in frequencies of CA-MRSA and community-acquired methicillin-sensitive S. aureus (CAMSSA) were evaluated. A total of 112 cases was evaluated. Of these, 35 (31.25%) were CA-MRSA. The rates of CA-MRSA had emerged from an increasing annual frequency of 9.5 cases per 10,000 SSTIs as of 2014 to 96.8 cases per 10,000 SSTIs in 2018. The ratio of cases with CA-MRSA to cases with CA-MSSA was 0 - 0.09 in two years of the study period and increased to a maximum ratio of 0.6 - 0.72 in the last two years. Consequently, the frequency of S. aureus in cases with SSTIs was significantly higher in 2016 - 2018 compared to the initial study period within the years of 2013-2015 [p < 0.001, relative risk increase: 7 (2.6-28.7) for CA-MRSA and p=0.002, relative risk increase: 2.1 (1.2-3.5)]. Cases with CA-MRSA increased approximately eight-fold during the six-year-study period. The rates of CA-MRSA in SSTIs among children increased significantly compared to CA-MSSA. The clinical impact of this increase should be evaluated, especially in patients with SSTI who are unresponsive to empirical treatment.

1000. HIV and the Treatment-Experienced Patient: The Positive Impact of Case-Based Education on Physicians’ Competence and Confidence

BackgroundDespite therapeutic advances, treatment-experienced HIV patients can present a clinical challenge, even to experienced care providers.Table. Assessment of Educational EffectivenessMethodsThis 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 < 0.05 are statistically significant. Effect sizes were evaluated using Cramer’s V (< 0.05 modest; 0.06-0.15 noticeable effect; 0.16-0.26 considerable effect; > 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.ResultsTo 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 < .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.ConclusionParticipation 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