Majority Of Episodes Research Articles

Predictors of mortality of Pseudomonas aeruginosa bacteraemia and the role of infectious diseases consultation and source control; a retrospective cohort study.

To determine predictors of mortality among patients with Pseudomonas aeruginosa bacteraemia. Retrospective study. This study conducted at the Lausanne University Hospital, Switzerland included adult patients with P. aeruginosa bacteraemia from 2015 to 2021. During the study period, 278 episodes of P. aeruginosa bacteraemia were included. Twenty (7%) isolates were multidrug-resistant. The most common type of infection was low respiratory tract infection (58 episodes; 21%). Sepsis was present in the majority of episodes (152; 55%). Infectious diseases consultation within 48h of bacteraemia onset was performed in 203 (73%) episodes. Appropriate antimicrobial treatment was administered within 48h in 257 (92%) episodes. For most episodes (145; 52%), source control was considered necessary, with 93 (64%) of them undergoing such interventions within 48h. The 14-day mortality was 15% (42 episodes). The Cox multivariable regression model showed that 14-day mortality was associated with sepsis (P 0.002; aHR 6.58, CI 1.95-22.16), and lower respiratory tract infection (P < 0.001; aHR 4.63, CI 1.78-12.06). Conversely, interventions performed within 48h of bacteraemia onset, such as infectious diseases consultation (P 0.036; HR 0.51, CI 0.27-0.96), and source control (P 0.009; aHR 0.17, CI 0.47-0.64) were associated with improved outcome. Our findings underscore the pivotal role of early infectious diseases consultation in recommending source control interventions and guiding antimicrobial treatment for patients with P. aeruginosa bacteraemia.

Electroconvulsive Therapy (ECT): A Scotland Wide Naturalistic Study of 4,826 treatment episodes

IntroductionDespite its apparent efficacy in the treatment of a range of psychiatric disorders, electroconvulsive therapy (ECT) is viewed by some as a contentious treatment. Although most clinicians and researchers consider ECT a safe and effective treatment, there are ongoing and significantly publicised concerns about potential side effects.ObjectivesTo explore use of ECT across Scotland in a large naturalistic clinical sample across an 11-year period from 2009 to 2019. To consider the efficacy and side effects of ECT for a range of common psychiatric disorders including, depression, bipolar depression, schizophrenia, and mania.MethodsUsing data from the Scottish Electroconvulsive Therapy (ECT) Accreditation Network (SEAN), information was collected for all adults who had received ECT. Variables included age, sex, Scottish Index of Multiple Deprivation (SIMD) quintile, International Classification of Diseases, Tenth Edition (ICD-10) diagnosis, indication for ECT, Mental Health Act status, consent status, entry and exit Montgomery-Asberg Depression Rating Scores (MADRS), entry and exit Clinical Global Index Severity CGI-S) scores and reported side effects. Side effects were recorded as present if the side effect was reported at any point during the episode of treatment.Results4826 ECT episodes were recorded. The majority of episodes were in women (68.4%, n=3,301). Average age at treatment onset was 58.52 years. Males were slightly younger (m=58.24 years vs f= 58.65 years, p= 0.20). Mean number of treatments/episode was 9.59 (95% CI 9.32 – 9.85). Mean treatment dose delivered was 277.75mC (95%CI 272.88 – 282.63mC).2920 episodes of treatment had CGI-S entry and exit recorded. At entry, mean CGI-S indicated marked illness (5.03 95% CI 4.99-5.07). Recipients with schizophrenia had the highest CGI-S score (5.45 95% CI 5.21-5.60), followed by those with post-partum disorders (5.38, 95% CI 4.61-6.14). At exit, mean CGI scores indicated borderline illness (2.07, 95% CI 2.03-2.11), recipients diagnosed with mixed affective state had the lowest CGI-S score (1.72, 95% CI 0.99-2.47) followed by those with schizoaffective disorder (2.01, 95% CI 1.76-2.42).Anaesthetic complications (n=34) and prolonged seizures (n=38) were rare, occurring in &lt;1% of treatment episodes. Cardiovascular complications were reported in 2.2% (n= 102). Nausea was reported in 7.2% (n= 334) and muscle aches in 12% (n=560). Confusion was reported in 19% (n=879) and cognitive side effects were reported in 26.2% (n=1212). One third of treatment episodes reported confusion or cognitive side effects (33.1%, n=1545).ConclusionsFrom this large naturalistic clinical sample, ECT appears to be effective in improving illness severity as measured by CGI-S score. While some side effects (such as prolonged seizures and cardiovascular complications) were rare, others (such as confusion or cognitive side effects) were relatively common.Disclosure of InterestNone Declared

Predictors of Mortality of Streptococcal Bacteremia and the Role of Infectious Diseases Consultation: A Retrospective Cohort Study.

Streptococcal bacteremia is associated with high mortality. Thia study aims to identify predictors of mortality among patients with streptococcal bacteremia. This retrospective study was conducted at the Lausanne University Hospital, Switzerland, and included episodes of streptococcal bacteremia among adult patients from 2015 to 2023. During the study period, 861 episodes of streptococcal bacteremia were included. The majority of episodes were categorized in the Mitis group (348 episodes; 40%), followed by the Pyogenic group (215; 25%). Endocarditis was the most common source of bacteremia (164; 19%). The overall 14-day mortality rate was 8% (65 episodes). The results from the Cox multivariable regression model showed that a Charlson comorbidity index >4 (P .001; hazard ratio [HR], 2.87; confidence interval [CI]: 1.58-5.22), Streptococcus pyogenes (P = .011; HR, 2.54;CI: 1.24-5.21), sepsis (P < .001; HR, 7.48; CI: 3.86-14.47), lower respiratory tract infection (P = .002; HR, 2.62; CI: 1.42-4.81), and absence of source control interventions within 48 hours despite being warranted (P = .002; HR, 2.62; CI: 1.43-4.80) were associated with 14-day mortality. Conversely, interventions performed within 48 hours of bacteremia onset, such as infectious diseases consultation (P < .001; HR, 0.29; CI: .17-.48) and appropriate antimicrobial treatment (P < .001; HR, .28; CI: .14-.57), were associated with improved outcome. Our findings underscore the pivotal role of infectious diseases consultation in guiding antimicrobial treatment and recommending source control interventions for patients with streptococcal bacteremia.

When symptoms are more than reflux.

45 year-old male patient with history of heartburn and regurgitation of non-acid food in the immediate postprandial period, with no symptomatic improvement after anti-acid treatment. The patient underwent an upper endoscopy that was unremarkable. A high-resolution impedance manometry (HRIM) was performed according to Chicago Protocol 4.0, as well as an additional solid test meal, with findings of rumination syndrome (RS) (figure 1). The study was completed with a 24-hour impedance pH monitoring that showed, in the immediate postprandial period, episodes of reflux that reached the proximal sensor followed by a normal swallow (figure 2). Abdominophrenic biofeedback was started with clinical improvement and anti-acid treatment was maintained at once a day. Discussion: RS is diagnosed by a complete clinical history, using the Rome IV or DSM-5 criteria (figure 3). Due to lack of knowledge of the disease and the fact that regurgitation can be present in other conditions including gastroesophageal reflux disease and achalasia, most patients undergo multiple tests and visit several physicians before reaching the diagnosis1. The gold standard investigation for RS, in cases where there are diagnostic doubts, is HRIM with solid meal administration, that shows a sudden increase in intragastric pressure > 30 mmHg concurrent with a drop in impedance and both simultaneous lower and upper esophageal sphincter relaxation, that may or may not be followed by re-swallowing food2. Rumination episodes can appear spontaneously (type 1) or may be preceded by a reflux episode (type 2) or a supragastric belch (type 3)3. 24-hour impedance pH monitoring cannot confirm de diagnosis, but during rumination, in the majority of episodes, the refluxed material reaches the proximal esophagus2.

Episodes of regime transformation

This article provides a new conceptualization of regime transformation that allows scholars to address democratization and autocratization as related but obverse processes. We introduce a dataset that captures 680 episodes of regime transformation (ERT) from 1900 to 2019 and offers novel insights into regime change over the past 120 years. The ERT has three main advantages over other approaches. First, it avoids problematic assumptions of unit homogeneity and constant as well as symmetric effects. Second, it integrates key insights from qualitative studies by treating regime change as a gradual and uncertain process. Third, the ERT is based on a unified framework for studying regime transformation in either direction. The dataset differentiates between four broad types of regime transformation: liberalization in autocracies, democratic deepening in democracies, and autocratization in both democracies and autocracies (democratic and autocratic regression). It further distinguishes ten patterns with distinct outcomes, including standard depictions of regime change (i.e. democratic transition or breakdown). A minority (32%) of ERTs produce a regime transition, with the majority of episodes either ending before a transition takes place or not having the potential for such a transition (i.e. further democratization in democratic regimes or further autocratization in autocratic regimes). We also provide comparisons to other datasets, illustrative case studies to demonstrate face validity, and a discussion about how the ERT framework can be applied in peace research.

SILENT MYOCARDIAL ISCHEMIA IN PATIENTS WITH ACUTE CORONARY SYNDROME AND DIABETES MELLITUS

ST-segment elevation myocardial infarction, stenting of the infarct-related coronary artery, silent (painless) myocardial ischemia, diabetes mellitus, 24-hour electrocardiographic monitoring.&#x0D; Introduction. Currently, approximately 422 million people in the world have diabetes mellitus, and over 1.3 million individuals in Ukraine are diagnosed with diabetes mellitus. Diabetic neuropathy is known to contribute to the development of atypical and painless variants of ischemic heart disease in individuals with diabetes. This poses a challenge for timely diagnosis and obscures the course of ischemic heart disease, as the prevalence of silent myocardial ischemia is significantly high in these patients. Therefore, the aim of this study is to investigate the occurrence of myocardial ischemia episodes in patients with ST-elevation myocardial infarction within the first day following stenting of the infarct-related coronary artery. Furthermore, we aimed to demonstrate the painless nature of these episodes in the presence of type 2 diabetes mellitus through a clinical case presentation.&#x0D; Materials and methods. 30 patients with ST-segment elevation myocardial infarction were examined, and 24-hour electrocardiographic monitoring was performed during the first day after the infarct-related coronary artery stenting. Results. Episodes of transient myocardial ischemia were registered in 50% of people. We found that the majority of episodes (80%) were painless. In the presence of diabetes mellitus, only episodes of painless myocardial ischemia were noted that is supported by the example of a clinical case. The study highlighted the informativeness of 24-hour electrocardiographic monitoring in identifying episodes of myocardial ischemia, particularly in its painless variant. The results demonstrate that patients with ST-elevation myocardial infarction (STEMI) experience episodes of transient myocardial ischemia within the first day after coronary artery stenting, with a majority of these episodes being painless. Furthermore, in the presence of diabetes mellitus, ischemic episodes tend to be painless. Therefore, 24-hour electrocardiographic monitoring serves as a valuable method for the detection of myocardial ischemia.

A content analysis of 32 years of Shark Week documentaries.

Despite evidence of their importance to marine ecosystems, at least 32% of all chondrichthyan species are estimated or assessed as threatened with extinction. In addition to the logistical difficulties of effectively conserving wide-ranging marine species, shark conservation is believed to have been hindered in the past by public perceptions of sharks as dangerous to humans. Shark Week is a high-profile, international programming event that has potentially enormous influence on public perceptions of sharks, shark research, shark researchers, and shark conservation. However, Shark Week has received regular criticism for poor factual accuracy, fearmongering, bias, and inaccurate representations of science and scientists. This research analyzes the content and titles of Shark Week episodes across its entire 32 years of programming to determine if there are trends in species covered, research techniques featured, expert identity, conservation messaging, type of programming, and portrayal of sharks. We analyzed titles from 272 episodes (100%) of Shark Week programming and the content of all available (201; 73.9%) episodes. Our data demonstrate that the majority of episodes are not focused on shark bites, although such shows are common and many Shark Week programs frame sharks around fear, risk, and adrenaline. While criticisms of disproportionate attention to particular charismatic species (e.g. great whites, bull sharks, and tiger sharks) are accurate and supported by data, 79 shark species have been featured briefly at least once. Shark Week's depictions of research and of experts are biased towards a small set of (typically visual and expensive) research methodologies and (mostly white, mostly male) experts, including presentation of many white male non-scientists as scientific experts. While sharks are more often portrayed negatively than positively, limited conservation messaging does appear in 53% of episodes analyzed. Results suggest that as a whole, while Shark Week is likely contributing to the collective public perception of sharks as bad, even relatively small alterations to programming decisions could substantially improve the presentation of sharks and shark science and conservation issues.

Clinical profile and microbiological spectrum of patients with continuous ambulatory peritoneal dialysis-associated peritonitis at a tertiary care center

BackgroundWe present risk factors, clinical profile, and microbiological spectrum of patients with continuous ambulatory peritoneal dialysis (CAPD)-associated peritonitis who were managed at our center. MethodsAll consecutive patients with CAPD-associated peritonitis who presented to our center between July 2018 and December 2019 were included in the study. Risk factors, microbiological spectrum, clinical profile, and outcome of patients were studied. ResultsEighty-five patients with CAPD-associated peritonitis and 50 patients who never had peritonitis during the study period were included. Diabetes Mellitus (OR 0.058, 95% CI0.007–0.493, p < 0.05), residence in rural area (OR 3.376, 95% CI 1.084–10.516, p < 0.05), duration of peritoneal dialysis (OR 0.935, 95% CI 0.886–0.987, p < 0.05), mean serum hemoglobin (OR 1.674, 95% CI 1.119–2.502, p < 0.05) and serum albumin (OR 0.148, 95% CI 0.066–0.333, p < 0.05) were associated with higher risk of peritonitis in CAPD patients. Eight-three patients (98.8%) had turbid CAPD fluid and 52 (61.2%) had fever at the time of presentation to the hospital. The mean CAPD fluid TLC on day 1, 3, and 5 were 2034.3 ± 3330.1 cells/cumm, 1049.0 ± 1210.9 cells/cumm, and 605.2 ± 950.5 cells/cumm, respectively. The organisms isolated were two Escherichia coli (2.4%), one Staphylococcus aureus (1.2%), one Klebsiella (1.2%), two Acinetobacter (2.4%), 10 Fungal organisms (11.7%), and in two (2.4%) cases, Mycobacterium tuberculosis (MTB) was detected by polymerase chain reaction (PCR) of CAPD fluid. Thirty-seven (43.5%) patients had a complete cure and 48 (56.5%) patients were refractory to treatment; hence catheter was removed in them (catheter loss). Six (7.0%) patients died during the study period. ConclusionCAPD-associated peritonitis is an important risk factor for technique failure. The majority of episodes are culture-negative, and PCR can help in detecting fungal and tubercular peritonitis early in the course.

Protocolo diagnóstico diferencial de la diarrea de origen infeccioso

Infectious diarrhea is the most common cause of acute diarrhea. It encompasses two large groups: watery diarrhea, which is the most common type and is mainly caused by viruses, bacteria, and parasites with little invasive capacity, and inflammatory diarrhea, characterized by feces with blood and mucus, fever, and abdominal pain and which has longer incubation and resolution times. The majority of episodes are self-limited in a few days and do not require microbiological study. It is important to properly evaluate these patients in order to identify those that require studies in order to identify the microorganism involved and the need for targeted treatment.

Early Descriptions of Family Caregivers' Experiences With Unexpected Lucidity

To develop an operational definition of and typologies for episodes of lucidity (EL), we conducted a cross-sectional study of former/current family caregivers from UsAgainstAlzheimer’s A_LIST (N = 538). More than 60% of caregivers (n = 294, 62%) reported witnessing EL with their care recipient over the course of their dementia. Most episodes happened in late stages of dementia (71%). Only 10% happened within 7 days before death. The majority of episodes (71%) lasted <30 minutes. About half the episodes were characterized by uncharacteristic speech and communication. Caregivers perceived these experiences positively (M = 4.10; range = 1–5), but also expressed desire to know why/when EL occurs and how to best respond to it. Data will be used to refine definitions and typologies, and then a prospective, demographically diverse survey will be administered to family caregivers to assess predictors of EL, linking EL to caregiver well-being and bereavement response.

403 - Episodes of lucidity (paradoxical lucidity): A survey of family caregivers of persons with dementia

Abstract:People with late-stage Alzheimer’s disease and related dementias (ADRD) who are assumed to have lost coherent cognitive capacity may exhibit unexpected episodes of spontaneous, meaningful, and relevant communication or behavior. Most reports of paradoxical lucidity or “episodes of lucidity” (EL) are anecdotal or case studies. Given the transient nature and lack of scientific explanation of the phenomenon, EL is under-investigated and poorly understood.To develop an operational definition of and typologies for EL, we conducted a pilot study of former and current family caregivers from UsAgainstAlzheimer’s A-LIST® (N = 480). Over sixty percent of caregivers (n = 294, 61%) reported witnessing at least one EL with their care recipient over the course of dementia. Most episodes happened in late stages of dementia (71%). Only 10% happened within 7 days before death. The majority of episodes (71%) lasted &lt;30 minutes. About half the episodes were characterized by uncharacteristic speech and communication. Caregivers perceived these experiences positively (M = 4.1; range = 1–5), but also expressed desire to know why/when EL occurs and how to respond to it.We plan to use these data to refine definitions and typologies to incorporate into a prospective, demographically diverse survey to family caregivers to assess predictors of EL and linking EL to caregiver well-being and bereavement response. Precise and robust operationalizations of EL will allow future research to assess if EL has different effects on ADRD prognosis or alters how family members understand, manage and adapt to a PLWD’s dementia progression.

A Descriptive Analysis of the Demographics and Presenting Symptoms of Patients in the U.S. Thrombotic Microangiopathy (USTMA) TTP Registry

Background:Immune Thrombotic Thrombocytopenic Purpura (iTTP) is a rare life-threatening thrombotic microangiopathy. TTP is clinically defined as microangiopathic hemolytic anemia and thrombocytopenia in adults without an alternative cause. The other three symptoms in the classical pentad - fever, altered mental status and kidney injury - are no longer mandatory for diagnosis. iTTP is defined by a deficiency in ADAMTS13, a protease that cleaves von Willebrand Factor. Laboratory confirmation of ADAMTS13 deficiency plus autoantibodies and/or inhibitors is frequently delayed. Therefore, early clinical suspicion of iTTP is imperative in order to initiate treatment and decrease mortality.The presenting symptoms and demographics of patients with iTTP have been previously reported by the Oklahoma TTP registry (Vesely, 2003). This registry consists of 142 patients from Oklahoma with idiopathic TTP, a subset of which was deficient in ADAMTS13. In this abstract we present a descriptive analysis of demographics and presenting symptoms in patients with laboratory-confirmed iTTP from the USTMA TTP registry; an eight-institution registry spanning six US states. Additionally, we compared the presenting symptoms and demographics of our registry with the findings in the Oklahoma TTP registry.Objectives:To report demographics and the prevalence of specific precipitating events and presenting symptoms of iTTP in patients enrolled in the USTMA TTP registry.Methods:Following IRB approval at each institution, investigators independently reviewed patient records and any patients who met the determined definition of iTTP were included in the registry. Immune TTP was defined as ADAMTS13 < 10% or ADAMTS13 < 20% with an inhibitor or antibody detected. Demographic and disease-related information, including precipitating events, presenting symptoms was collected by review of electronic medical records.Results:181 patients with 316 distinct episodes of confirmed iTTP are currently included in the USTMA TTP registry. Demographic and clinical data are reported in Tables 1 and 2. The majority of patients who presented with TTP were female (74%). The ethnicity of patients was almost evenly split between Caucasian (49.2%) and Black or African American (44.1%). In comparison, the Oklahoma registry was 80% female and 37% Black or African American, differences that are not statistically significant (p 0.3 and p 0.1). No precipitating event was identified in the majority of episodes (76.4%). Infection was most common (13.5%) followed by initiation of new medications or supplements (8.8%). The most common presenting symptoms of iTTP included petechiae or easy bruising (25.7% of episodes), focal neurologic deficits (23.8%) and fatigue (22.8%). Other common symptoms included other neurologic findings including confusion (16.3%) and headache (18.6%), as well as fever (13.7%) and abdominal pain (18.6%). Many episodes had multiple symptoms and in 20.8% of episodes there were no reported symptoms.18 patients in the Oklahoma registry met our inclusion criteria and we compared the symptoms of our patients to that cohort (Vesely, 2003). The most common symptoms in their cohort were gastrointestinal (55%), higher than we observed although we only specifically measured abdominal pain. Notably, they had a similar percentage of patients present with severe neurologic findings (28%), which included focal neurologic deficits. This observation of focal deficits is potentially interesting given that TTP-associated neurologic symptoms have more commonly been described as global deficits including altered mental status.Conclusions:iTTP is a rare, life-threatening disease that requires prompt identification and treatment. The USTMA TTP registry is the largest and only multicenter US iTTP registry to date. It offers the opportunity to analyze and report the demographics and common presenting symptoms of iTTP to aid in recognition and diagnosis. When compared with the Oklahoma TTP registry, the best-studied iTTP cohort in the US, we found similar demographic distributions, with both women and African-Americans being overrepresented. We also found similar proportions of patients who presented with focal neurologic symptoms, as opposed to the more commonly described altered mental status. Abdominal pain/GI symptoms were less frequent in the USTMA TTP registry compared with the Oklahoma TTP registry. [Display omitted] DisclosuresSadler:BioMarin: Consultancy; Genentech: Consultancy; Ablynx: Consultancy; 23andMe: Consultancy.

Characteristics and outcome in an Egyptian Cohort with status epilepticus

Status epilepticus (SE) is an important cause of mortality worldwide. Information regarding associations of mortality outcome in Egypt is limited. The main objective of this study was to describe the clinical characteristics and factors associated with mortality of patients with SE admitted to Cairo University Hospitals. A prospective observational hospital-based study was conducted from January 2017 to June 2018. Patients with SE aged ≥12years old were followed with documentation of outcome on discharge as survival versus death. The study cohort included 144 SE patients. The majority of episodes (96.5%) were with prominent motor features, while nonconvulsive SE occurred in 3.5%. There was a clear semiology evolution in 22.9% of episodes, 56.3% had unchanging semiology (e.g., just convulsive or just nonconvulsive) and the semiology evolution could not be discerned in 20.8%. In relation to treatment, the majority of cases were responsive (46.5%), whereas 43.1% were refractory and only 10.4% were super-refractory SE. Apart from seven patients who were referred to other hospitals, 99 patients survived whereas 38 (26.4%) died. After regression analysis, only absence of a history of epilepsy, semiology evolution and mechanical ventilator use were associated with mortality increasing its odds by 3.7, 5, 111 times, respectively. Absence of a history of epilepsy, SE semiology evolution, and mechanical ventilator use was found to be associated with mortality outcome among Egyptian patients with SE.

CON

There is a considerable overlap of psychotic and mood symptoms in patients with severe mental disorders, and a large proportion of patients meeting diagnostic criteria experience significant mood symptoms. The diagnosis of schizophrenia – schizoaffective type /schizoaffective disorder has been a part of the Diagnostic and statistical manual since the DSM-I. Even if the need for a diagnosis capturing this particular clinical picture obviously is needed, the agreement about when to use the diagnosis of schizoaffective disorder as well as the diagnostic reliability is low. There is an agreement that the diagnosis covers episodes with an overlap between a psychotic episode meeting the A criteria for schizophrenia and a major mood episode where the psychotic symptoms continue after the end of the mood symptoms. Given the prevalence of depression in schizophrenia, some episodes, however, meet the criteria for schizoaffective disorders while others do not. The DSM-5 thus argues that the pattern of overlapping symptoms should be present in the majority of episodes. Keeping the cross-sectional approach favoured by previous versions of the DSM and the ICD will here continue to spread diagnostic confusion.DisclosureNo significant relationships.

Cohort profile: development and characteristics of a retrospective cohort of individuals dispensed prescription opioids for non-cancer pain in British Columbia, Canada

PurposePrescription opioids (POs) are widely prescribed for chronic non-cancer pain but are associated with several risks and limited long-term benefit. Large, linked data sources are needed to monitor their harmful...

1362. Antibiotic Prescribing for Acute Otitis Media in Commercially Insured Pediatric Patients in the United States

BackgroundOverprescribing of antibiotics to treat conditions that are self-limiting and do not always require antibiotics is a well-recognized concern in pediatric care. The 2013 American Academy of Pediatrics (AAP) acute otitis media (AOM) guidelines reinforced previous recommendations regarding watchful waiting for three days among patients with non-recurrent uncomplicated AOM and provided more explicit diagnostic criteria.MethodsWe conducted a retrospective cohort study using the IBM Marketscan Commercial Claims Research Databases (2008-2018). Pediatric patients 1 to 12 years old were included. We required a primary diagnosis of AOM in an outpatient setting, without AOM or other complicated ear infections within 6 months prior and no other acute infections in the 2 weeks prior to or 1 week after AOM diagnosis. Patients were classified as treated (pharmacy dispensing record of antibiotics within 3 days of diagnosis) or watchful waiting (no treatment or treatment after > 3 days). We used segmented linear regression to examine changes in treatment proportions across the study period.ResultsWe identified 2,640,920 pediatric AOM episodes, of which 2,033,697 (77.0%) were treated within 3 days. The majority of episodes were treated with amoxicillin (51.3%), followed by amoxicillin/clavulanate (15.3%) and cephalosporins (22.0%). Among episodes in the watchful waiting group, 18,793 (3.1%) filled a prescription within 4-7 days of diagnosis. Most patients saw a pediatrician (62.7%). A larger proportion of otolaryngologists adopted watchful waiting approaches compared to other physician types. There was no difference in chronic conditions or regional variation between the two groups. There was no immediate (p=0.31) or gradual change in treatment proportion (p=0.49) after release of the 2013 guidelines.ConclusionMost pediatric patients continue to be treated with antibiotics within three days of AOM diagnosis, reflecting no impact of the 2013 AAP guidelines. Physician specialty but not patient characteristics appear to determine treatment approaches.DisclosuresNicole Smolinski, PharMD, Nothing to disclose

1480. Incidence of Non-Invasive Pneumococcal Pneumonia in Children in the United States before and after Introduction Pneumococcal Conjugate Vaccines (PCV7 and PCV13) during 1998-2018

BackgroundPneumonia causes significant pediatric morbidity, mortality, and healthcare resource utilization. S. pneumoniae is a leading cause of bacterial pneumonia in children. Merck is developing V114, an investigational 15-valent PCV that contains PCV13 serotypes as well as 22F and 33F. To demonstrate the potential value of V114, it is important to estimate the remaining burden associated with pneumococcal pneumonia (PP). This study was to estimate incidence rates (IRs) of non-invasive PP before and after PCV7 and PCV13 introduction in children in the US.MethodsPP-related claims in children < 18 years were identified in the IBM MarketScan® Commercial database (1998-2018) using pneumococcal specific ICD9/10 codes. Claims with any invasive pneumococcal disease ICD9/10 codes were excluded. An episode could comprise one or more claims. Episodes with any inpatient stays were categorized as inpatient, and as outpatient otherwise. Age-stratified (< 2, 2-4, and 5-17 years) IRs were episodes per 100,000 patient-years (PYs) during the pre-PCV7 (1998-1999), early and late PCV7 (2001-2005, 2006-2009), and early and late PCV13 (2011-2013, 2014-2018) periods.ResultsInpatient and outpatient PP IRs decreased steadily in children < 2 years (146.8, 117.9, 102.0, 67.8, and 32.2 per 100,000 PYs for pre-PCV7, early and late PCV7, and early and late PCV13 periods, respectively; Figure 1). In children 2-4 years, IRs increased slightly from 88.6 to 90.0 per 100,000 PYs from the pre-PCV7 to early PCV7 period, then declined to 83.9 and 30.8 per 100,000 PYs in the late PCV7 and late PCV13 periods, respectively (Figure 2). In children 5-17 years, IRs declined from 35.3 to 34.2 per 100,000 PYs from the pre-PCV7 to early PCV7 period, stabilized at 34.1 per 100,000 PYs in the late PCV7 period, followed by a steeper decline to 12.5 per 100,000 PYs in the late PCV13 period (Figure 3). The majority of episodes were outpatient in all three age groups.Figure 1. Non-invasive pneumococcal pneumonia incidence in children <2 years, episodes per 100,000 patient-years (1998 - 2018) Figure 2. Non-invasive pneumococcal pneumonia incidence in children 2 - 4 years, episodes per 100,000 patient-years (1998 - 2018) Figure 3. Non-invasive pneumococcal pneumonia incidence in children 5 - 17 years, episodes per 100,000 patient-years (1998 - 2018) ConclusionIn children < 2 years, IRs of non-invasive PP decreased after introduction of PCV7 and PCV13. Following introduction of PCV 7 and PCV13, there remains a residual burden of non-invasive PP in children in the US. The impact of future PCVs on PP will depend on the proportion of PP caused by S. pneumoniae and vaccine-type serotypes.DisclosuresTianyan Hu, PhD, Merck (Employee, Shareholder) Yan Song, PhD, Merck (Consultant) Nicolae Done, PhD, Merck & Co., Inc. (Consultant) Qing liu, PhD, Merck (Consultant) James Signorovitch, PhD, Merck & Co., Inc. (Consultant) Tanaz Petigara, PhD, Merck & Co., Inc. (Employee, Shareholder)

Incidence, Clinical Features, and Outcomes of Late-Onset Neutropenia From Rituximab for Autoimmune Disease.

Late-onset neutropenia (LON) is an underrecognized complication of rituximab treatment. We undertook this study to describe its incidence, risk factors, clinical features, management, and recurrence. We conducted a single-center retrospective cohort study of 738 adult patients with autoimmune disease who were treated with rituximab to induce continuous B cell depletion. The primary outcome measure was LON, defined as an unexplained absolute neutrophil count of <1,000 cells/µl during B cell depletion. Secondary outcome measures included incidental diagnosis, fever, sepsis, filgrastim use, and recurrent LON. We assessed predictors of LON using Cox proportional hazards regression models. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated. We identified 107 episodes of LON in 71 patients. The cumulative incidence at 1 year of B cell depletion therapy was 6.6% (95% CI 5.0-8.7). The incidence rate during the first year was higher compared to thereafter (7.2 cases per 100 person-years [95% CI 5.4-9.6] versus 1.5 cases per 100 person-years [95% CI 1.0-2.3]). Systemic lupus erythematosus and combination therapy with cyclophosphamide were each independently associated with an increased risk of LON (adjusted HR 2.96 [95% CI 1.10-8.01] and 1.98 [95% CI 1.06-3.71], respectively). LON was not observed in minimal change disease or focal segmental glomerulosclerosis. The majority of episodes (59.4%) were asymptomatic. Fever and sepsis complicated 31.3% and 8.5% of episodes, respectively. Most patients (69%) were treated with filgrastim. Rituximab rechallenge occurred in 87% of patients, of whom 21% developed recurrent LON. LON is common and often incidental. Most cases are reversible and respond well to filgrastim. However, LON can be associated with serious infections and thus warrants vigilant monitoring.

Automated identification of patients with syncope in the textual health record – a feasibility study using machine learning and natural language processing

Abstract Background Syncope is a commonly occurring presenting symptom in emergency departments. While the majority of episodes are benign, syncope is associated with worse prognosis in hypertrophic cardiomyopathy, arrhythmia syndromes, heart failure, aortic stenosis and coronary heart disease. Flagging documented syncope in these patients may be crucial to management decisions. Previous studies show that the International Classification of Diseases (ICD) codes for syncope have a sensitivity of around 0.63, leading to a large number of false negatives if patient identification is based on administrative codes. Thus, in order to provide data-driven, clinical decision support, and to improve identification of patient cohorts for research, better tools are needed. A recent study manually annotated more than 30.000 patient records in order to develop a natural language processing (NLP) tool, which achieved a sensitivity of 92.2%. Since access to medical records and annotation resources is limited, we aimed to investigate whether an unsupervised machine learning and NLP approach with no manual input could achieve similar performance. Methods Our data was admission notes for adult patients admitted between 2005 and 2016 at a large university hospital in Norway. 500 records from patients with, and 500 without a “R55 Syncope” ICD code at discharge were drawn at random. R55 code was considered “ground truth”. Headers containing information about tentative diagnoses were removed from the notes, when present, using regular expressions. The dataset was divided into 70%/15%/15% subsets for training, validation and testing. Baseline identification was calculated by a simple lexical matching using the term “synkope”. We evaluated two linear classifiers, a Support Vector Machine (SVM) and a Linear Regression (LR) model, with a term frequency–inverse document frequency vectorizer, using a bag-of-words approach. In addition, we evaluated a simple convolutional neural network (CNN) consisting of a convolutional layer concatenating filter sizes of 3–5, max pooling and a dropout of 0.5 with randomly initialised word embeddings of 300 dimensions. Results Even a baseline regular expression model achieved a sensitivity of 78% and a specificity of 91% when classifying admission notes as belonging to the syncope class or not. The SVM model and the LR model achieved a sensitivity of 91% and 89%, respectively, and a specificity of 89% and 91%. The CNN model had a sensitivity of 95% and a specificity of 84%. Conclusion With a limited non-English dataset, common NLP and machine learning approaches were able to achieve approximately 90–95% sensitivity for the identification of admission notes related to syncope. Linear classifiers outperformed a CNN model in terms of specificity, as expected in this small dataset. The study demonstrates the feasibility of training document classifiers based on diagnostic codes in order to detect important clinical events. ROC curves for SVM and LR models Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Research Council of Norway

2 Systemic glucocorticoids and bradycardia in critically ill children: a retrospective study

Abstract Background Glucocorticoids are widely used in the pediatric population. They are associated with numerous side effects including repercussions on the cardiovascular system. The impact on heart rate is not well known, but bradycardia has been reported, mostly with high doses. Objectives We described the occurrence of bradycardias and the variation of heart rate in critically ill children receiving glucocorticoids. Design/Methods We conducted a retrospective study including 1 month old to 18 year old children admitted to the Pediatric Intensive Care Unit between 2014 and 2017, who received a glucocorticoid dose equivalent to 1 to 15 mg/kg/day of prednisone. We collected data on exposition to glucocorticoids, heart rate before, during and after the exposition, and interventions from the medical staff in response to bradycardia. The primary outcome was the occurrence of bradycardia and the secondary outcomes were the magnitude of heart rate variation and the clinical management of bradycardias. Results We included 92 admissions (85 patients). The median dose of glucocorticoid used was 2.80 mg/kg/day of prednisone (2.08—3.80). We found 70 cases (76%) with at least one bradycardia. Before treatment, all patients had a mean heart rate higher than the 5th percentile for age. During exposition to glucocorticoids, 8 patients (10%, n = 83) had a median heart rate ≤ 5th percentile. We noted 46 cases of bradycardia (50%) that led to an intervention from the medical staff, but no patient had a major event associated to bradycardia. We found a significant association between bradycardia and age (estimate -0.136, 95% CI -0.207—-0.065, p &amp;lt; 0.001), glucocorticoid dose (estimate 4.820, 95% CI 2.048—7.592, p &amp;lt; 0.001) and intravenous administration (estimate 8.709, 95% CI 1.893—15.524, p = 0.012). Conclusion In our study, most children hospitalized at the intensive care unit receiving standard doses of glucocorticoid experienced bradycardia. The majority of episodes led to an intervention from the medical staff. Presence of bradycardia was associated with younger age, higher dose and IV administration of glucocorticoids.