Olive View-UCLA Medical Center Research Articles

WEO Newsletter.

WEO Newsletter.

Improving Self-management of Type 2 Diabetes in Latinx Patients: Protocol for a Sequential Multiple Assignment Randomized Trial Involving Community Health Workers, Registered Nurses, and Family Members

The rate of Type 2 diabetes mellitus (T2DM) among Mexican American individuals is 16.3%, about twice that of non-Hispanic White individuals. While a number of education approaches have been developed and shown to improve diabetes self-management behaviors and glycemic control for Spanish-speaking Latinx patients with T2DM, there is little research to guide health practitioners regarding which interventions to apply and when so that resources are used efficiently, and treatment outcomes are maximized. This study aimed to describe an adaptive intervention that integrates community mental health workers, diabetes nurse educators, family members, and patients as partners in care while promoting diabetes self-management for Mexican American individuals with T2DM. The project incorporates four evidence-based, culturally tailored treatments to determine what sequence of intervention strategies work most efficiently and for whom. Given the increasing prevalence of T2DM, achieving better control of diabetes and lowering the associated medical complications experienced disproportionally by Mexican American individuals is a public health priority. Funded by the National Institute of Nursing Research (National Institutes of Health grant R01 NR015809), this project used a sequential multiple assignment randomized trial and included 330 Spanish-speaking Latinx patients with T2DM. In the first phase of the study, subjects were randomly assigned to an evidence-based diabetes self-management educational program called Tomando Control delivered in a group format for 6, biweekly 1.5-hour sessions, led either by a community health worker or a diabetes nurse educator. In the second phase of the study, those subjects who did not improve their diabetes self-management behaviors were rerandomized to receive either an augmented version of Tomando Control or a multifamily group treatment focused on problem-solving. The primary outcome measure was the "Summary of Diabetes Self-Care Activities." Evaluations were made at baseline and at 3, 6, and 12 months. This study was funded in June 2016 for a period of 5 years. Institutional review board approval was obtained in November 2016. Between March 2017 and September 2020, a total of 330 patients were recruited from the outpatient primary care clinics of Olive View-UCLA Medical Center, with a brief hiatus between May 2020 and July 2020 due to COVID-19 restrictions. The study interventions were completed in December 2020. Data collection began in March 2017 and was completed in December 2021. Data analysis is expected to be completed in Spring 2023, and results will be published in Fall 2023. The results of this trial should help practitioners in selecting the optimal approach for improving diabetes self-management in Spanish-speaking, Latinx patients with T2DM. ClinicalTrials.gov NCT03092063; https://clinicaltrials.gov/ct2/show/NCT03092063. DERR1-10.2196/44793.

Editorial introductions.

Editorial introductions.

1777. Shorter Versus Longer Antibiotic Durations for Coagulase-Negative Staphylococcus Catheter-Related Bloodstream Infections and Potential Impact on Antimicrobial Stewardship in a County Hospital

Abstract Background Coagulase negative Staphylococcus (CoNS) is a common cause of catheter-related bloodstream infection (CRBSI). Current guidelines are to provide 10-14 days (d) of antibiotics (abx) plus lock abx in the absence of catheter removal, and if the catheter has been removed, 5-7 d after removal. Olive View UCLA-Medical Center (Sylmar, CA) is an academic county hospital, serving the medical needs of the underserved community. The purpose of this study was to evaluate differences in treatment (tx) durations for CoNS CRBSI on clinical outcomes and evaluate the potential impact on antimicrobial stewardship. Methods Single center retrospective chart review from January 2018 to December 2021 on all central line-obtained blood cultures (Bcx) positive for CoNS. Exclusion criteria included suspected contamination or no abx tx, invasive CoNS infection, and concomitant infection treated with abx that have activity against CoNS. Duration of abx tx was divided into two groups: >10 d vs ≤10 d with or without catheter removal and >7 d vs ≤7 d post catheter removal. Primary outcomes assessed were recurrence of CoNS CRBSI within 90 d and 30 d hospital readmission. Secondary outcomes included hospital length of stay (LOS), 30 d all-cause mortality, and days of Bcx positivity. Groups were compared using Wilcoxon rank-sum for continuous variables and Fisher’s exact for categorical variables using Stata (Version 15). Results 153 positive CoNS central line Bcx were screened, 40 met study inclusion. 37 received vancomycin as initial abx with a median total tx duration of 13.5 d [IQR 8-14] and 9 d [IQR 6-13.5] after line removal. 22 (55%) received total abx duration of >10 d and 18 (45%) received total abx duration of ≤10 d. Baseline characteristics were similar between >10 d and ≤10 d (table 1). There was no significant difference in primary and secondary outcomes, respectively, between >10 d and ≤10 d (table 2). After catheter removal, there were no significant differences in outcomes whether antibiotics were continued for >7 d (n=18) vs ≤7 d (n=15) (table 3). Table 1:Baseline CharacteristicsTable 2:Outcomes according to days of therapyTable 3:Outcomes post catheter removal days of therapy Conclusion Abx tx duration of ≤10 d compared with >10 d for CoNS CRBSI did not result in differences in 90 d recurrence and 30 d readmission. Shorter courses of tx for CoNS CRBSI should be considered as a target for antimicrobial stewardship to minimize antibiotic exposure. Disclosures All Authors: No reported disclosures.

173. Antimicrobial Stewardship Education Changes Prescribing Behavior and Reduces Treatment of Asymptomatic Bacteriuria

BackgroundTreatment of asymptomatic bacteriuria (ASB) outside of pregnancy and urological procedures increases the risk of antibiotic resistance without improving outcomes. At Olive View-UCLA Medical Center (Sylmar, CA), the CDC U.S. Antibiotic Awareness Week (AAW) was utilized as a platform to promote antimicrobial stewardship (AS) for ASB. We evaluated the incidence of antibiotic treatment of ASB pre-AAW vs post-AAW, and the impact of AS education on future prescribing practices for ASB.MethodsIn this single-center retrospective observational study, AS education defining ASB vs urinary tract infection (UTI) was provided via visual aids distributed throughout the hospital during AAW from 11/18/2020 to 11/24/2020 (Figure 1). All positive urine cultures (Ucx) for adult inpatients were reviewed prior to AAW from 9/2020 to 11/2020 and after AAW from 12/2020 to 1/2021. Patients were excluded if they were unable to report UTI symptoms, pregnant, or undergoing urological procedure. The incidence of ASB treatment pre- and post-AAW was compared. A survey was sent to providers to compare the impact on antibiotic prescribing behavior for ASB pre- and post-AAW. Fisher’s exact and Chi-squared tests were used for statistical analysis.Figure 1. Antimicrobial Stewardship Education and Poster Distribution ResultsA total of 260 cases met study eligibility. In the pre-AAW group, 56 of 131 cases presented with ASB, of which 16 were treated with antibiotics (28.6%). In the post-AAW group, 55 of 129 cases presented with ASB, and 5 were treated with antibiotics (9.1%). Antibiotics were prescribed more often for patients with ASB in the pre-AAW group compared to those in the post-AAW group (p=0.014). Forty providers completed the survey, of which 97.5% had seen the visual aids, 70% had found the education "very” or “extremely" useful, and 43.6% reported they “always or sometimes” treated ASB pre-AAW vs 15% post-AAW (p< 0.01).ConclusionAS posters and education defining ASB significantly decreased the treatment of ASB. AAW education on ASB antimicrobial stewardship demonstrated a high value and shifted prescribing behavior to avoid antibiotic treatment of ASB. A similar approach to deliver provider education could serve as a valuable model to change provider AS practices for ASB.Disclosures All Authors: No reported disclosures

Receptiveness and barriers to clinical trial participation for oncology patients from a public safety-net hospital.

83 Background: Oncologic clinical trial enrollment is low, particularly in underserved populations. Increasing enrollment of public safety-net hospital patients is important to ensure representation of the general population and reduces cancer outcome disparities. To tailor clinical trial outreach, we sought to characterize attitudes towards trial participation of oncology patients at Olive View—UCLA Medical Center (OVMC), a public safety-net hospital in Los Angeles County. Methods: We developed a 39-question survey (Qualtrics, Provo, UT). It was administered via tablets to a convenience sample of patients in OVMC’s medical oncology clinic and infusion center during 2020—2021. The survey was offered to patients fluent in English or Spanish. Results: Of 165 patients who were offered the survey, 11 declined due to illiteracy in any language, 4 did not finish the survey. Median age was 54 (range: 20-81); 63% were female. The majority (76%) reported an annual income below $25,000; 39% did not complete high school. Self-identified ethnicity was Hispanic/Latino (73%), non-Hispanic White (12%), Asian-Pacific Islander (9%), and Black (4%). Based on a 5-point Likert scale of comfort speaking English, 48% had English proficiency (EP). Overall, 69% of patients expressed interest in trials. When considering participation, patients would seek advice from their physician (86%), family (32%), other medical staff (14%), alternative medicine practitioner (7%), friend (6%), or religious leader (4%). Concerns regarding trial participation were lack of knowledge regarding trials (47%), fear of side effects (43%), frequent visits (25%), cost (20%), transportation (14%), wage loss (9%), and inability to determine own treatment (4%). Patients found the following modalities useful for learning about trials: website (43%), paper handout (39%), video (37%), discussion with prior participants (34%). Patients with annual income &gt; $25,000 were significantly more concerned about cost (33.3% v. 15.8%, p = 0.04) and treatment side effects (61.1% v. 36.8%, p = 0.02). EP patients were more likely to find a website (54.2% vs. 32.1%, p = 0.01) or discussion with prior participants (45.8% v. 23.1%, p &lt; 0.01) helpful compared to low EP patients. Conclusions: There is considerable interest in oncologic clinical trials in this predominantly Hispanic/Latino population. This population had significant trust in physicians for guidance on trial enrollment, and had minimal concern for out-of-pocket cost, wage loss, or transportation issues. The majority of patients did not find additional informational resources helpful. Structural barriers rather than patient-level variables are likely the primary drivers of low oncologic trial enrollment. Future efforts should focus on improving access to appropriate trials and leveraging the physician-patient relationship for increasing trial participation.

Technology and social media use by oncology patients with limited english proficiency at a safety net hospital.

e18533 Background: Prior studies have shown that when patients with cancer engage with social media, they have positive outcomes, including clinical trial participation, volunteerism and advocacy, and diminished levels of anxiety. However, active users of social media tend to be white, well-educated, and of higher socioeconomic status. Little is known about the use of technology and social media by underserved oncology populations, particularly patients with limited English proficiency (LEP). We sought to characterize current technology use by patients at Olive View—UCLA Medical Center (OVMC), a safety net hospital in Los Angeles County. Methods: We developed an anonymous online survey (Qualtrics, Provo, UT) comprised of 39 questions. The survey was administered, via touchscreen tablets from January 2020 through January 2021, to a convenience sample of patients seen in OVMC’s outpatient medical oncology clinic. The survey was available in English and Spanish, and we excluded patients who were not fluent in either language. Patients were categorized as having LEP versus English proficiency (EP) by self-assessment, on a 5-point Likert scale, of their comfort in speaking English. Differences between the LEP and EP groups were assessed using Pearson’s chi-squared test and Fisher’s exact test. Results: Of 113 patients who were offered the survey, 10 (9%) declined participation because of illiteracy in their primary language or inability to use a tablet. Reponses were recorded for 50 patients with LEP and 53 with EP. The LEP and EP groups, respectively, were similar in their representation of women (62% and 64%) and mean age (58 years and 51 years). High school completion rates were 32% for the LEP group and 70% for the EP group. A higher proportion of the LEP group identified as Hispanic/Latinx (84%) compared to the EP group (58%). The LEP group was less likely than the EP group to have internet access (63% vs. 98%, P&lt; 0.01). However, among patients with internet access, social media use was similar in the LEP and EP groups (65% vs. 71%, P= 0.7). Facebook was the most used platform by the LEP (22%) and EP (32%) groups; other platforms (e.g., Twitter, Instagram) were used by very few respondents. The LEP group was less likely than the EP group to have activated the OVMC online patient portal (19% vs. 47%, P&lt; 0.01) and less likely to perceive websites as helpful for learning about clinical trials (30% vs. 53%, P= 0.03). Conclusions: A notable proportion of safety net oncology patients at OVMC do not engage with tablet technology because of illiteracy or lack of comfort with touchscreens. Patients with LEP are less likely to have internet access, but those with access use social media about as often as patients with EP, and prefer Facebook over other platforms. For patients with LEP, engagement efforts, including clinical trial outreach, should continue to include non–internet-based resources in patients’ native languages.

Improving access to timely pain management in an underserved oncology clinic: A palliative care-oncology partnership.

e18672 Background: In the 4 years since inception, the palliative care (PC) clinic at Olive-View UCLA Medical Center (OVMC) cared for less than 6% of pain-positive cancer patients based on guidelines put forth by ASCO. As with other under-resourced safety-net settings, the demand for PC services at OVMC far exceeds the manpower available for optimal pain management in oncology patients. This year long project aims to improve pain management in a busy oncology clinic via enhanced identification and prompt treatment of cancer pain by Oncologists. Methods: At the project start, Oncologists were surveyed to identify key elements to be incorporated into formal didactics on pain management principles, case-based discussions and real-time mentoring. At the weekly oncology clinic, patients were screened for pain using the multi-modal PEG scale: Average Pain intensity (P), interference with Enjoyment of life (E), and interference with General activity (G) over the preceding week. The Oncologist was notified of the PEG score if a patient had an average score ≥4 (0-10 scale) for review and intervention. Patients were screened using the same method at subsequent visits. EHR of patients with PEG scores ≥4 were reviewed to determine whether therapeutic interventions were made by the Oncologist. A comparison of PEG scores to the standard nursing intake pain scores was also conducted. Results: Over a 4-month period, 513 PEG forms were administered, 37% of which resulted in a pain score ≥4. Of the 172 patients who screened positive, 54 patients were screened at follow up visit(s). Comparing the pain-positive cohort, we observed an average decrease in pain by 25.5% (7.1 to 5.3) in patients who received intervention as opposed to 7.4% (5.0 to 4.7) in patients who did not receive intervention by their Oncologist. Further, there was a remarkable divergence between the average PEG score (6.7) and nurse intake pain score (1.4) in this patient cohort. Conclusions: Our findings suggest that improved Oncologist real-time pain assessment and intervention incorporating a validated pain screening tool leads to timely pain management in cancer patients. Implementation of a Palliative Care-Oncology partnership promotes provider awareness and confidence in treating patients with complex pain. A functional pain assessment, using PEG, can more accurately reflect pain compared to the current standard nursing intake process. Particularly in resource challenged settings where access to PC is limited, facilitating timely pain management through training and mentoring of oncologists or other primary providers can be a sustainable model to improve patient access to primary palliative care. Given the early indicators of success we hope to expand this workflow in training other healthcare providers within our County safety net system. Research Sponsor: California Health Care Foundation.

Rates of inflammatory bowel disease in Hispanics comparable to non-Hispanic Whites: results of a cohort study.

Previous studies have suggested that inflammatory bowel disease (IBD) occurs at higher rates among non-Hispanic Whites (NHWs) compared to other ethnicities; however, Hispanics as the largest minority in the United States remain underrepresented in IBD research and we hypothesize that they have similar rates of IBD. We examined the epidemiology, demographics, clinical presentation, and treatment of IBD in a predominantly Hispanic cohort in Los Angeles (LA) County. This was a retrospective cohort study based at Olive View-UCLA Medical Center, one of the three major safety-net hospitals in LA County. Electronic medical records from 2015 to 2018 were queried, and biopsy-proven cases of IBD (n = 170) were identified. Outcomes included the incidence and prevalence of IBD, disease distribution, treatment, and IBD-related surgery. The incidence of IBD among Hispanics was 175 (95% confidence interval [CI] 127-240) and 113 (95% CI 62-200) for NHWs per 100,000 person-years. Prevalence of IBD per 100,000 people was 418 (95% CI 341-512) for Hispanics and 557 (95% CI 431-739) for NHWs. Notably, the proportion of Hispanic IBD patients with a history of smoking was 21.5% vs 50.8% in NHWs (p = 0.011). There were no significant differences between the two groups with regard to Montreal classification, pharmacotherapy, or IBD-related surgery. In one of the largest US studies of Hispanics with IBD, and the only one to have both clinical and histopathologic confirmation as inclusion criteria, we found the incidence and prevalence of IBD among Hispanics to be higher than previously recognized and comparable to NHWs. Additionally, Hispanic IBD patients had lower rates of smoking compared to NHWs.

S0216 Rates of Inflammatory Bowel Disease in Hispanics Comparable to Non-Hispanic Whites: Results of a Large Cohort Study

INTRODUCTION: Inflammatory bowel disease (IBD) has historically been believed to occur at higher rates among non-Hispanic Whites compared to other ethnicities. However, current epidemiological understanding of IBD within the United States (US) has been drawn from research consisting of primarily non-Hispanic White cohorts with scant ethnoracial diversity. Hispanics are the fastest growing and the largest minority group in the US, yet they remain grossly underrepresented in studies of IBD. With this study, we aimed to better understand the epidemiology, demographics, clinical presentation, and treatment of IBD in the Hispanic population in Los Angeles County. METHODS: Our study was based at Olive View-UCLA Medical Center (OVMC), one of three safety net hospitals that comprise the Los Angeles Department of Health Services (LADHS). We queried pathology reports from 2015 to 2018 for key terms to identify biopsy-confirmed cases of IBD (N = 170) and abstracted pertinent data from electronic health records. Incidence and prevalence for ethnicities were standardized using their respective proportions in the composition of the OVMC patient population. Statistical analyses included two-proportion t-test, analysis of variance, binomial proportion confidence interval, general linear model and logistic regression. RESULTS: Of the 170 biopsy-confirmed cases of IBD, Hispanics represented 55% of all patients. The annual incidence rate per 100,000 patients for IBD among Hispanics was 175 (95% confidence interval [CI] 127–240) vs. 113 (95% CI 62–200) among non-Hispanic Whites. The prevalence of IBD per 100,000 patient-years was 418 (95% CI 341–512) for Hispanics and 557 (95% CI 431–739) for non-Hispanic Whites. In the subset with Crohn’s disease, smoking rates were significantly lower in Hispanics as compared to non-Hispanic Whites (12.9 vs 62.9%, P = 0.033). There was no significant difference between the two ethnic groups with regard to medical treatment, IBD-related surgery, presenting symptoms, or Montreal classification of disease. CONCLUSION: To our knowledge this is the largest US-based study of Hispanics with biopsy-confirmed IBD. The findings, herein, indicate that the incidence and prevalence of IBD among Hispanics in the US is higher than previously reported and comparable to rates among non-Hispanic Whites.Table 1.: Ethnic background of patients with biopsy-confirmed IBD, Olive View-UCLA Medical Center, Los Angeles County, 2015–2018Table 2.: Demographics of Hispanic and NHW patients with biopsy-confirmed IBD, Olive View-UCLA Medical Center, Los Angeles County, 2015–2018

Pick Up Your Probes: A Call for Clinically Oriented Point-of-Care Ultrasound Research in COVID-19.

Journal of Ultrasound in MedicineVolume 40, Issue 2 p. 391-396 Commentary Pick Up Your Probes: A Call for Clinically Oriented Point-of-Care Ultrasound Research in COVID-19 Alan T. Chiem MD, MPH, Corresponding Author Alan T. Chiem MD, MPH [email protected] orcid.org/0000-0002-2243-1915 Department of Emergency Medicine, Olive View–UCLA Medical Center, Sylmar, California, USA Address correspondence to Alan T. Chiem, MD, MPH, Department of Emergency Medicine, Olive View–UCLA Medical Center, 14445 Olive View Dr, North Annex, Sylmar, CA 91342, USA. E-mail: [email protected]Search for more papers by this authorJacqueline Shibata MD, MS, Jacqueline Shibata MD, MS orcid.org/0000-0002-3615-5907 Department of Emergency Medicine, Olive View–UCLA Medical Center, Sylmar, California, USASearch for more papers by this authorGeorge Lim MD, George Lim MD Ronald Reagan UCLA Medical Center, California, Los Angeles, USASearch for more papers by this authorYiju Teresa Liu MD, RDMS, Yiju Teresa Liu MD, RDMS orcid.org/0000-0003-0087-5790 Harbor–UCLA Medical Center, West Carson, California, USASearch for more papers by this author Alan T. Chiem MD, MPH, Corresponding Author Alan T. Chiem MD, MPH [email protected] orcid.org/0000-0002-2243-1915 Department of Emergency Medicine, Olive View–UCLA Medical Center, Sylmar, California, USA Address correspondence to Alan T. Chiem, MD, MPH, Department of Emergency Medicine, Olive View–UCLA Medical Center, 14445 Olive View Dr, North Annex, Sylmar, CA 91342, USA. E-mail: [email protected]Search for more papers by this authorJacqueline Shibata MD, MS, Jacqueline Shibata MD, MS orcid.org/0000-0002-3615-5907 Department of Emergency Medicine, Olive View–UCLA Medical Center, Sylmar, California, USASearch for more papers by this authorGeorge Lim MD, George Lim MD Ronald Reagan UCLA Medical Center, California, Los Angeles, USASearch for more papers by this authorYiju Teresa Liu MD, RDMS, Yiju Teresa Liu MD, RDMS orcid.org/0000-0003-0087-5790 Harbor–UCLA Medical Center, West Carson, California, USASearch for more papers by this author First published: 20 July 2020 https://doi.org/10.1002/jum.15394Citations: 2 All of the authors of this article have reported no disclosures. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume40, Issue2February 2021Pages 391-396 RelatedInformation

Retrospective Analysis of HER2+ Breast Cancer Outcomes at a County Hospital: Do Published Outcomes Hold up in the Real World?

Introduction: Landmark trials repeatedly demonstrate that pertuzumab and trastuzumab plus standard chemotherapy have the best outcomes in human epidermal growth factor receptor 2 (HER2) positive breast cancer in the neoadjuvant, adjuvant, and metastatic setting. However, many of these multicenter landmark trials lack diversity and studied largely Caucasian populations. Our goal is to address this under-representation of minorities, and compare pathologic complete response (pCR) rates in our predominantly Hispanic population with HER2 positive breast cancer receiving the same neoadjuvant chemotherapy (NACT) at Olive View-UCLA Medical Center (OVMC) to that of pCR rates observed in the TRYPHAENA trial.Methods: For this retrospective cohort study, we compiled a list of 53 patients aged 18 and older, 52 female and 1 male, with HER2 positive breast cancer identified by fluorescence in situ hybridization treated at OVMC from December 2015 to May 2018. Our population was 57% Hispanic, 13% white, 13% Filipino, 11% Asian, 2% black, and 4% other. The complete list included patients receiving standard neoadjuvant, adjuvant, and metastatic chemotherapy regimens. We analyzed 23 female patients with HER2 positive breast cancer staged I to IIIC, receiving standard NACT (docetaxel, carboplatin, trastuzumab, and pertuzumab). Metastatic HER2 positive breast cancer patients were excluded. The primary outcome studied was pCR rates after receiving NACT. pCR was defined as the absence of invasive cancer cells from tissue samples removed after surgery. Secondary outcomes measured were side effects of chemotherapy. pCR rates and side effects were compared to TRYPHAENA. Data regarding insurance status, breast cancer detection modality, and time to seek medical attention were recorded.Results: 50% of our patients who received NACT achieved pCR. Our pCR rates mirrored those observed in the TRYPHAENA trial (51.9%). The most common side effect observed in our population was diarrhea. A higher proportion (37.5%) of our patients had liver function test (LFT) elevation compared to the TRYPHAENA trial (3.9%). Baseline LFTs were normal prior to treatment in 96% of patients. In terms of modality of detection, 70% were self-palpated, 26% were detected through routine mammography, and 4% were found incidentally. Average time from mass discovery to seeking medical attention was 3.4 months. Only 26% had medical insurance at diagnosis. Although not included in our study, 28% of our patients were initially diagnosed with stage IV metastatic disease. Conclusion: Our study found that pCR rates in our primarily Hispanic population compared well to the response rates observed in landmark trials with largely Caucasian populations. Genetic variations in chemo-sensitivity may have a minimal influence on cancer care outcomes in this population.

1093. Evaluation of an Antimicrobial Stewardship Elective Rotation for Medicine Residents

BackgroundIn 2017, an Antibiotic Stewardship (ASP) elective was established for the medicine residents to engage directly in stewardship practice, learn how to communicate recommendations effectively to their peers, and gain further understanding of the rationale for antimicrobial stewardship. Recommendations are co-formulated with the ID Pharmacist and ID Attending Physician, and documented as an ASP Note in the electronic health record. Additionally, the residents disseminate recommendations via page and verbal communication to their peers. The purpose of this study was to evaluate the response of the primary care teams to guidance formulated and communicated by the residents while on this clinical elective.MethodsRecommendations by the medicine residents participating on the ASP elective from January 2018 to July 2018 were reviewed. Response to the recommendations was categorized as accepted, not accepted, or partially accepted with alternative change. Recommendations were considered as accepted if changes were made by the primary team within 24 hours from time of the ASP note. Responses were further reviewed based on the following medical services: medicine (including hematology/oncology), surgery, and intensive care (ICU).ResultsA total of 124 recommendations were reviewed for response.11 of the patients were excluded as changes either occurred prior to the documentation of the ASP note, or proposed changes did not pertain to antibiotic management. Ninety-four of the included interventions were accepted. Medicine, surgery, and ICU services accepted 84%, 82.4%, and 83.3% of recommendations, respectively. The services did not accept 5%, 11.8%, and 11.1% of recommendations, and partial acceptance with alternative changes was 11%, 5.8%, and 5.6%, respectively.ConclusionRecommendations formulated and communicated by residents participating in the ASP Elective rotation resulted in a high degree of acceptance. The acceptance rates did not differ significantly between the medical services. The addition of the ASP Elective has demonstrated a benefit to the ASP program at Olive View-UCLA Medical Center, and other medical residency training programs should consider implementation of such an elective rotation to enhance stewardship efforts and medical resident education.Disclosures All authors: No reported disclosures.

ChemoPalRx: Development and implementation of a chemotherapy mobile provider order entry system in a safety net hospital.

73 Background: Computerized provider order entry (CPOE) systems have been shown to enhance the safety and efficiency of prescribing chemotherapy over the handwritten ordering process. However, many institutions lack the financial ability, technological capability, or operational flexibility to invest in and implement such a system. In particular, Olive View-UCLA Medical Center (OVMC), a Los Angeles County safety net hospital, is among these institutions with unique restrictions that preclude the use of chemotherapy CPOE and mandate handwritten orders. Methods: In an effort to bridge the gap for safe chemotherapy prescribing, we aimed to develop and implement an effective, scalable, and sustainable chemotherapy provider order entry solution that was operationally sensitive to institutions without a chemotherapy CPOE. The solution was designed as a mobile application using Xcode, the integrative development environment of Apple Inc., with the Swift programing language. Results: On September 5th, 2018, we launched a free, chemotherapy provider order entry solution on the worldwide Apple App Store – ChemoPalRx. Using ChemoPalRx, providers can search, customize, and print common chemotherapy regimens in prescription format. Along with a reference library of over 120 order set and 450 medications, ChemoPalRx is equipped with the functions to automate dosage calculation, suggest pre-medications and safety parameters, and trigger alerts for missing prescribing information. As a quality improvement initiative, we implemented ChemoPalRx at OVMC. Implementation stages include obtaining administrative buy-in, consulting with multidisciplinary staffs, investing $100 USD for a prescription printer, and encouraging providers to download ChemoPalRx on their own mobile devices. An ongoing prospective cohort study is being conducted to determine ChemoPalRx effectiveness in reducing errors compared to handwritten orders. Conclusions: ChemoPalRx is developed to enhance the safety and efficiency of chemotherapy prescribing. Implementation of this mobile application is feasible in the safety-net hospital setting and has the potential to transform oncology practices globally.

727 Clinical Epidemiology of Inflammatory Bowel Disease in Los Angeles County: A Study of a Predominantly Latino Population

INTRODUCTION: The body of research pertaining to the epidemiology, features, and treatment of inflammatory bowel disease (IBD) continues to grow; however, relatively little remains known about IBD in minority populations. Hispanics and Blacks have been understudied in most population studies, often comprising &lt;2% of the sample size. This disproportion limits the ability to formulate reliable conclusions regarding ethnoracial influences on incidence, phenotype, severity of disease, and outcomes in these minority groups. To help address this void, we initiated a population-based study of the clinical epidemiology of IBD in Los Angeles County Department of Health Services (LADHS), the second largest municipal healthcare system in the United States. The ethnoracial makeup of the county is comprised predominantly of Latino patients, which provides a unique opportunity to evaluate IBD in a population that has not been well-studied to date. METHODS: We conducted a retrospective cohort study of all biopsy-proven cases of IBD diagnosed between November 2015 and June 2018 at Olive View-UCLA Medical Center, one of three hospitals comprising LADHS. Patient and disease-related data such as age, gender, ethnicity, presenting symptoms and laboratory values, and complications, were collected using a standardized data collection tool and tabulated. RESULTS: One hundred and twenty-six cases of IBD were found, of which 42 were new diagnoses, suggesting an incidence and prevalence of 160 and 481 per 100,000 person-years, respectively. Among these 126 patients, 79% were Latino, with the average age of diagnosis at 36.4 years. 54% of patients were female. The most common diagnosis was ulcerative colitis (43%), with Crohn's and indeterminate colitis making up 29% and 28% of patients, respectively. The most common presenting symptoms were bloody diarrhea and abdominal pain, both of which occurred more frequently in patients diagnosed with Crohn's disease. CONCLUSION: Both the prevalence and incidence in this predominantly Hispanic cohort are significantly higher than reported rates for IBD by the Center of Disease Control (CDC), Furthermore, this cohort appears to have unique clinical characteristics, with UC more common in females, Crohn's disease more common in males, and a large proportion of patients having indeterminate colitis. Further evaluation is needed to better understand the characteristics, etiopathogenesis, and outcomes of IBD, as well as reduce healthcare disparities in this historically understudied population.

1220 Clinical Epidemiology of Gastric Signet Ring Cell Carcinoma in a Safety Net County Setting

INTRODUCTION: Signet ring cell carcinoma is a rare but increasingly incident histotype of gastric cancer. Historically, this histotype (GSRC) has been known for its dismal prognosis; however, studies evaluating the clinical features and natural history of GSRC, particularly in the United States (US) and in minority populations, have been lacking. Thus, we examined the occurrence, clinico-demographic characteristics, oncologic features, treatment, and outcomes of GSRC in a predominantly minority county hospital setting and benchmarked them against data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. METHODS: We identified all biopsy-proven GSRC cases at our Los Angeles County hospital (Olive View-UCLA Medical Center) between 2004-2017 through a retrospective histopathology database and prospective endoscopic repository. Pertinent data were collected from medical records with a standardized abstraction sheet and examined using descriptive statistics. Survival (measured as time to death or initiation of hospice) was calculated using the Kaplan-Meier method and compared with the log-rank test. Where applicable, cohort data were compared to SEER data. RESULTS: A total of 63 patients with GSRC were identified, of which 81% were Hispanic. Compared with SEER data, patients in this cohort were younger (mean age at diagnosis 52.6 vs 63.5 years), majority female (57% vs 45%), had higher T staging (T3 and T4 stage in 76.7% vs 60.7%), and more frequent lymph node involvement (89.2% vs 48.5%). Longer survival was seen in patients with lower tumor stage (P = 0.001), H. pylori infection (P = 0.017), and surgical intervention (P &lt; 0.001). Overall median survival was slightly longer in this cohort compared to SEER (12.6 vs 10.0 months). CONCLUSION: Patients with GSRC in this safety net hospital cohort have different clinical characteristics compared to what has been reported in SEER. Patients in our cohort were younger and more often female, and despite having more advanced disease, did not have shorter survival. Further study is needed and underway to better identify protective and risk factors in this population and improve understanding of the etiopathogenesis and natural history of this malignancy.

ChemoPalRx: Development and implementation of a chemotherapy mobile provider order entry system in a safety net hospital.

e18071 Background: Computerized provider order entry (CPOE) systems have been shown to enhance the safety and efficiency of prescribing chemotherapy over the handwritten ordering process. However, many institutions lack the financial ability, technological capability, or operational flexibility to invest in and implement such a system. In particular, Olive View-UCLA Medical Center (OVMC), a Los Angeles County safety net hospital, is among these institutions with unique restrictions that preclude the use of chemotherapy CPOE and mandate handwritten orders. Methods: In an effort to bridge the gap for safe chemotherapy prescribing, we aimed to develop and implement an effective, scalable, and sustainable chemotherapy provider order entry solution that was operationally sensitive to institutions without a chemotherapy CPOE. The solution was designed as a mobile application using Xcode, the integrative development environment of Apple Inc., with the Swift programing language. Results: On September 5th, 2018, we launched a free, chemotherapy provider order entry solution on the worldwide Apple App Store – ChemoPalRx. Using ChemoPalRx, providers can search, customize, and print common chemotherapy regimens in prescription format. Along with a reference library of over 120 order set and 450 medications, ChemoPalRx is equipped with the functions to automate dosage calculation, suggest pre-medications and safety parameters, and trigger alerts for missing prescribing information. As a quality improvement initiative, we implemented ChemoPalRx at OVMC. Implementation stages include obtaining administrative buy-in, consulting with multidisciplinary staffs, investing $100 USD for a prescription printer, and encouraging providers to download ChemoPalRx on their own mobile devices. An ongoing prospective cohort study is being conducted to determine ChemoPalRx effectiveness in reducing errors compared to handwritten orders. Conclusions: ChemoPalRx is developed to enhance the safety and efficiency of chemotherapy prescribing. Implementation of this mobile application is feasible in the safety-net hospital setting and has the potential to transform oncology practices globally.

JPEN Journal Club 34. Suspecting Causation in an Association.

Journal of Parenteral and Enteral NutritionVolume 42, Issue 4 p. 826-828 Journal Club JPEN Journal Club 34. Suspecting Causation in an Association Ronald L. Koretz MD, Corresponding Author Ronald L. Koretz MD rkoretz@msn.com orcid.org/0000-0002-6632-138X Emeritus Professor of Clinical Medicine, Olive View-UCLA Medical Center, David Geffen-UCLA School of Medicine, Sylmar and Los Angeles, California, USA Corresponding Author: Ronald L. Koretz, MD, Olive View-UCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342, USA. Email: rkoretz@msn.comSearch for more papers by this author Ronald L. Koretz MD, Corresponding Author Ronald L. Koretz MD rkoretz@msn.com orcid.org/0000-0002-6632-138X Emeritus Professor of Clinical Medicine, Olive View-UCLA Medical Center, David Geffen-UCLA School of Medicine, Sylmar and Los Angeles, California, USA Corresponding Author: Ronald L. Koretz, MD, Olive View-UCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342, USA. Email: rkoretz@msn.comSearch for more papers by this author First published: 30 March 2018 https://doi.org/10.1002/jpen.1155Citations: 1 Financial disclosure: None declared. Conflicts of interest: None declared. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume42, Issue4May 2018Pages 826-828 RelatedInformation

Signet ring cell gastric carcinoma: A descriptive analysis of a unique county population.

32 Background: Signet ring cell type gastric carcinoma (SRCC) is an uncommon epithelial malignancy of the stomach, with data from the United States (US) being particularly scarce. Compared to other gastric carcinoma types, it has a female predominance, younger age at diagnosis, and late presentation, making treatment particularly challenging. Recent reports suggest this disease may be increasing among even younger patients, for reasons which remain unclear. We aimed to examine the occurrence, features, and outcomes of SRCC in a predominantly minority Los Angeles County patient population. Methods: We identified all patients diagnosed with SRCC at Olive View-UCLA Medical Center (OVMC) from 2004-2017. Clinico-demographic, imaging, and pathologic data were reviewed and analyzed and compared descriptively to available Surveillance, Epidemiology, and End Results (SEER) data. Results: Sixty-six cases of SRCC were identified, of which 77% were Latino, 9% White, 6% Armenian, and the remaining 8% other. Mean age at SRCC diagnosis was 52 years, and 37 (56%) of patients were female. H. pylori infection was present in 35% (43% diagnosed by serum antibody, 35% by pathology, 9% by stool antigen, and 13% by combination). Follow-up was available for 91% of patients. Median survival was 1 year, and 5-year survival was 7%, markedly lower than the 31% reported in SEER. Seventy-two percent of patients were deceased or on hospice within 2 years of diagnosis. Conclusions: In this first US study to assess the clinical epidemiology of SRCC in a predominantly minority population: 1) the mean age of diagnosis was younger than reported in previous studies (55-61 years), 2) the proportion of males was high compared to SEER data, and 3) survival was considerably lower than previously reported. Insofar as the patient population in this study serves as a microcosm of surrounding underserved communities, it is likely that SRCC may be more common than expected in this vulnerable patient population, and that significant clinical differences may exist in presentation and outcomes of SRCC. In light of these differences, further research is needed to examine potential environmental and/or genetic risk factors or disparities which may be operational.

New Medications for the Treatment of Diabetes.

New Medications for the Treatment of Diabetes.