Activity Prescription Research Articles

578. Metformin reduces the risk of Long COVID or Death over 6 months in an Emulated Target Trial of Primarily Omicron-infected Adults without Diabetes or Prediabetes: a New-User, Active-Comparator Analysis Using the National COVID Cohort Collaborative (N3C) Electronic Health Record Database. This research was supported in part by the Intramural/Extramural research program of the National Center for Advancing Translational Science,

Abstract Background Metformin has decreased SARS-CoV-2 RNA in 4 cell lines. In a RCT of > 1,000 majority vaccinated outpatients, COVID-19 related ED visits/Hospitalization/Death occurred in 4.7% of the metformin vs 9.0% of the placebo group by Day 28; clinician-diagnosed Long Covid (LC) occurred in 6.2% of metformin vs 10.3% of placebo by Day 300; and 14% of metformin vs 23% of the placebo group had detectable nasal viral load on Day 10. In a trial of 20 adults, 60% of metformin vs 100% of placebo had detectable viral load by Day 4. Observational analyses report associations between prevalent metformin and less severe acute COVID. Given these data, we assessed whether metformin currently prevents LC. Cumulative Incidence Curve Cumulative incidence curves for the outcome of Long Covid/Death in the 180 Days after a metformin prescription (blue) or active comparator prescription (red). The increase in outcomes at Day 90 reflects the computable phenotype, which cannot be computed until 90 days after infection. Per data use requirements in the National Covid Cohort Collaborative (N3C), the starting number at risk is not shown due to small cell sizes or the ability to calculate small cell sizes. Methods We emulated a randomized trial of metformin vs. control in SARS-CoV-2-infected outpatients. Intervention: prescription for metformin within 6 days of infection. Control: prescription for fluvoxamine, fluticasone, ivermectin, or montelukast (drugs used off-label for Covid but clinical trials have shown no effect on acute COVID outcomes). Exclusions: age < 18; metformin or comparator prescribed within 365 days; indication for chronic metformin use; contraindication for metformin or control. Outcome: a composite of LC or Death (LC/D), LC defined by U09.9 or a symptom/condition based computable phenotype. We used entropy balancing to estimate the average treatment effect with a weighted log linear model. This is a forest plot showing metformin use versus active comparator use and the development of Long Covid/Death by Day 180. The black squares represent risk ratios (RR), and the lines represent 95% confidence intervals. The number of outcomes, denominators, and exact percentages are sometimes omitted so that cell sizes <10 are not able to be calculated, in accordance with the data use requirements in the National Covid Cohort Collaborative (N3C). The Pre-Omicron Era is larger than the Omicron era in both the Metformin and Comparator Cohorts, but the denominator for the Day 0-6 sample is not shown because of cell sizes <10. The subgroup of those with new Paxlovid use was too small to analyze, so we present only the subgroup who did not also receive a prescription for Paxlovid. Results After balancing, the standardized mean differences were < 0.01. Overall, most (5,787/9,660, 59.9%) were infected during Omicron. In the metformin and control groups, 16% and 17% were Black; 16% and 13% were Hispanic, respectively. In the metformin group, 10/248 (4.0%) developed LC/D vs. 21/248 (8.5%) in the control group, RR 0.47 (95% CI 0.25 to 0.89). For prescriptions on Days 0-1 relative to infection the RR was 0.39 (95% CI 0.12-1.24); for prescriptions on Days 0-14 the RR was 0.75 (95% CI 0.52-1.08). Cohort Balance Cohort balance of the standardized mean differences (SMD) before weighting (in pink), and after weighting (in teal), for the primary analysis. Conclusion Metformin prescribed within a week of SARS-CoV-2 infection was associated with a 53% reduction in LC/D. Anything between an 11% to 75% reduction in risk is highly compatible with our data. Important questions remain: are results consistent in randomized clinical trial data from adults with a normal body mass index and those previously infected with SARS-CoV-2.Table 1:Individuals who experienced death before the prescription could be started were excluded from the trial emulation to mimic both target trials (COVID-OUT and ACTIV-6), as they were both decentralized trials that entailed medication delivery to the home. Those who experienced hospitalization between -1 to 3 Days were also excluded to mimic the target trial: those who were hospitalized on Day -1 to 0 relative to infection could not have received and taken an outpatient prescription of metformin or comparator for their SARS-CoV-2; those hospitalized on Days 1 to 2 likely spent at least one day in the emergency department before hospitalization, so it is also unlikely that they received an outpatient prescription, obtained the prescription from a pharmacy, and took a dose before being hospitalized. Disclosures All Authors: No reported disclosures

P-504. Disparities in PrEP Coverage by Sex Among Individuals Diagnosed with Bacterial STIs in a Large Municipal Healthcare System

Abstract Background Nationally almost 20% of new HIV diagnosis are in females. Females carry 53% of sexually transmitted infection (STI) disease burden in the US, yet nationally represent only 10% of individuals on Pre-Exposure Prophylaxis (PrEP). The US Preventive Services Task Force and CDC include females diagnosed with bacterial STIs as one of the populations to be considered for PrEP. However, females are often not the focus of HIV PrEP campaigns, resulting in knowledge gaps, bias and stigma that further challenge PrEP access for women. As part of efforts to improve sexual health services and access within NYC's municipal healthcare system, we designed a sexual health dashboard (SHD) that included a “PrEP Eligible” metric focused on federal PrEP guidelines related to bacterial STIs. Methods All alive patients aged 13-75 years old with a primary care or women’s health clinic visit within a NYC Health and Hospitals facility during April 2023-March 2024 were included in the SHD. The SHD displays testing and positivity rates for Chlamydia, Gonorrhea, and Syphilis, in addition to PrEP eligibility and PrEP active status. PrEP eligibility is based on high frequency of HIV or STI tests (3+ in 1 year), an abnormal STI lab or STI diagnosis and ‘PrEP Active’ is defined as an active prescription for PrEP within the preceding 6-months. Results Females represented 82% of PrEP eligible patients but only 13.2% (162) of PrEP Active patients (1,223). Among all people with Chlamydia, 0.2% of females were PrEP Active compared to 16% of males. For Gonorrhea, 2.6% of females were PrEP Active compared to 44.3% of males. For Syphilis, 1.9% of females were PrEP Active compared to 18.6% of males (Figure 1). Conclusion According to the CDC, 6% of sexually acquired HIV can be attributed to bacterial STIs, however PrEP usage remains low among eligible females within a municipal healthcare system in NYC. Dedicated efforts are being made within NYC Health and Hospitals to expand PrEP to primary care and women’s health, with the hopes that diversifying care settings for PrEP will reach populations not currently accessing PrEP services. Lack of recognition of the connection between HIV risk and STIs may disproportionately impact females and contribute to underutilization of PrEP. Disclosures Emma Kaplan-Lewis, MD, Gilead Pharmaceuticals: Grant/Research Support

P0401 The IBD-disk accurately assesses disability and psychological burden at IBD diagnosis and predicts adverse outcomes in both UC and Crohn’s disease during the first year of treatment

Abstract Background Inflammatory bowel disease (IBD) is linked with increased prevalence of mental health diseases (MHD), particularly anxiety and depression. How this influences treatment outcomes is poorly studied at IBD diagnosis. The IBD disk is a patient-reported outcome measure that quantifies disease-associated disability. We aimed to determine if the disk can be used pre-diagnosis to screen for mental health symptoms and predict treatment outcomes. Methods Patients with suspected IBD were seen in a rapid-access clinic. An IBD disk was completed upon review, pre-diagnosis. A subgroup simultaneously completed the Hospital Anxiety and Depression scale (HADS). Repeat disks were completed after diagnosis, with 12-month outcomes collected prospectively. Results 188 patients completed a baseline disk (97 Crohn’s disease [CD], 91 Ulcerative colitis [UC]), 95 completed a simultaneous HADS and 82 completed a repeat disk. Both a pre-existing MHD diagnosis (CD 22%, UC 11%, X2 p=0.049) and an active anti-depressant prescription (CD 16%, UC 7%, X2 p=0.035) were more common at CD diagnosis than UC. The ‘Emotions’ domain correlated with HADS depression (rs=0.607 p<.001), anxiety (rs=0.586 p<.001) and reliably identified HADS defined moderate-severe depression (Area under the curve 0.873). A score ≥7 identified all patients meeting this HADS threshold (Sensitivity 100%, specificity 60.5%, Youden’s index 0.601). This is shown in Figure 1. Whilst the IBD Disk did not outperform traditional disease severity indices, elevated baseline disk scores in UC predicted the subsequent need for advanced therapies (p=0.019), persistent active disease at 12 months (p=0.023) and need for inpatient treatment (p<.001). In CD, elevated disk scores predicted need for advanced therapies (p=0.014), persistent active disease (p=0.015) and showed a weak association with the need for surgical resection within 12 months (p=0.064). These results are summarised in Table 1. After diagnosis and treatment, ongoing disability and psychological symptoms were driven by disease activity. In both UC and CD, the ‘Emotions’ domain fell significantly in those in remission at first follow-up (CD p<.001; UC p=0.008) but was unchanged when the disease remained active (CD p=0.71; UC p=0.72). Conclusion The IBD disk reliably screens for symptoms of depression and anxiety and identifies risk of adverse treatment outcomes at IBD presentation. Its use in the outpatient setting can support holistic disease assessment and identify those who are most likely to benefit from additional psychological support. Moreover, particularly in UC patients, elevated baseline IBD disk scores should prompt the consideration of treatment escalation early in the disease course.

Pneumococcal and Herpes Zoster Vaccination Rates Among U.S. Veterans With Chronic Inflammatory Disease on Biologic Medications: A Quality Improvement Project.

Patients with chronic inflammatory diseases are often treated with pharmacologic therapies that target the immune system and have an increased risk of infection. These risks can be reduced by vaccination against common pathogens. This quality improvement project aimed to increase pneumococcal and herpes zoster vaccination rates in patients with chronic inflammatory disease on biologic immunosuppressive therapy. This quality improvement project was developed and implemented at the Veteran Affairs (VA) hospital in Memphis, TN. A VA data warehouse query was used to identify veterans with an active prescription for a biologic immunosuppressant over 2 phases (phase 1 and phase 2) of the project. Clinical pathway and VA electronic medical record, e.g., Computerized Patient Record System order set for various biological agents and vaccines, were developed by the investigators over a period of 3 months before the activation of phase 1 and was approved by the Memphis VA Medical Center Pharmacy and Therapeutics Committee. The pathway and the order set were developed for providers prescribing biologic therapies to include a review of patient immunization status and the option to order vaccines before initiation of biologics. When a provider used the order set to order the biologic, the appropriate vaccine and laboratory tests were recommended on the order set to educate the provider to take the appropriate actions necessary before the medication was started. Charts of Veterans included in the study were reviewed to assess vaccination rates before and after the QI project implementation for each phase. Phase 1 occurred over a 1-year period (October 2018 to October 2019) and sought to increase pneumococcal vaccination (PV) rates in patients on biologic therapies compared to the preintervention period. Recombinant zoster vaccine was not included in this phase as it was not readily available at the Memphis VA Medical Center at that time. Phase 2 (November 2019 to April 2022) sought to increase pneumococcal and herpes zoster vaccination rates. During phase 1, pneumococcal vaccination rates improved from a 41% preintervention rate to 66% (P < .01). During phase 2, 73% of patients completed their pneumococcal vaccination series and 58% received PCV13, PPSV23 and at least 1 dose of Shingrix, compared to 30% in the preintervention period (P < .01). Provider education, clinical pathway, and Computerized Patient Record System order set can improve vaccination rates in patients with chronic inflammatory diseases on biologic immunosuppressive therapy.

Assessing the effectiveness of a rural distribution program in reducing time to prothrombin complex concentrate administration in patients taking warfarin

ABSTRACT Study Objectives Reversal of warfarin-induced anticoagulation using prothrombin complex concentrate (PCC4) is more rapidly achieved than with traditional methods such as fresh frozen plasma (FFP). In many rural facilities the availability of both FFP and PCC4 has been limited. A tertiary hospital instituted a program to provide PCC4 to rural sites using an air transport team and pharmacy exchange. We hypothesized that increasing accessibility of PCC4 would shorten time to INR reversal. Methods This was a retrospective study with the primary outcome being time to INR reversal (INR ≤1.6) and time to PCC4 administration from outside hospital admission. Active warfarin prescription, transfer to a tertiary facility, and administration of anticoagulation reversal between January 2013 and December 2020 were required for inclusion. Patients were grouped by dates before and after implementation of the program in August 2016. Linear regressions were performed to determine the effect of the variable and INR reversal methods on time to INR reversal as well as time to PCC4 administration. Time to event analysis was used to analyze the primary outcome between comparison groups. p values of less than 0.05 were considered significant. Results Chart review identified 189 patients: 56 within the pre-implementation group and 133 in the post- implementation group. Statistics were compared between these two groups. The post-implementation group had a shorter time to INR reversal (median 9.97 hours) compared with the pre-implementation group (median 14.58 hours, p = 0.00004). Time to PCC4 administration was also significantly decreased (p = 0.023). No statistically significant differences were found for hospital survival or 30-day mortality. Conclusion In rural hospitals, increasing availability of PCC4 using air medical transport along with a medication exchange program significantly reduces time to PCC4 administration in warfarin anticoagulated patients.

Assessing Prevalence of Nonmedically Used Prescription Drug Involvement in Overdose Deaths Through Linkage of State Unintentional Drug Overdose Reporting System and Controlled Substances Monitoring Program Data

Background While illicit substances are commonly involved in the overdose crisis, prescription substances still play a role. Oftentimes, decedents do not have prescriptions for these substances at the time of death. As such, we sought to examine the prevalence of nonmedical drug use in Tennessee through linkage of fatal drug overdose and prescription data. Methods We used State Unintentional Drug Overdose Reporting System (SUDORS) data to identify fatal drug overdoses in Tennessee from 2019 to 2022. Deaths were linked to Controlled Substances Monitoring Program data deterministically using name and date of birth. Nonmedical use was defined as a decedent having a prescription substance on toxicology but not having an active prescription for that substance at the time of death. Descriptive statistics were performed to assess prevalence overall and examine differences between drug classes. Results We identified 7,281 SUDORS deaths from January 2019–2022 with complete toxicology that were able to be linked to prescription data. The median age of decedents was 40 years with 34.2% female and 65.8% males. Prevalence of nonmedical use differed for each category, 1,263(17.3%) for nonmedical opioid use, 1,216(16.7%) for nonmedical benzodiazepine use, 436 (6.0%) for nonmedical gabapentin use, and 152 (2.1%) for nonmedical stimulant use. Overtime, nonmedical use of opioids, benzodiazepines, and stimulants has decreased. Conclusion Through linkage of fatal overdose and prescription data, we found the prevalence of nonmedical use to be 33% in Tennessee. Increasing education on the dangers of nonmedical use, the importance of safe drug disposal, storage, and only using medications as prescribed is encouraged to reduce improper use as the drug landscape continues to shift.

Evaluation of a Program Designed to Support Implementation of Prescribing Medication for Treatment of Opioid Use Disorder in Primary Care Practices.

Offering medication for opioid use disorder (MOUD) in primary care can increase access to effective opioid use disorder treatment and help address the US opioid crisis. We describe a primary care office-based opioid treatment program and addiction consultation service model designed to support small, rural clinics to increase their capacity for MOUD. This is an evaluation of an intervention to increase clinic capacity to offer MOUD. The intervention consists of a standardized curriculum, addiction medicine consultants, practice facilitation, and financial incentives. Fifteen Colorado primary care practices participated from January 2022 through January 2023. Primary outcomes included overall change in the number of active buprenorphine prescriptions and implementation of MOUD milestones before and after the intervention. The mean number of active buprenorphine prescriptions in the 3 months preceding the intervention (baseline) increased from 2.1 (SD = 7.7) to 11.3 (SD = 11.2) at 13 months. Adjusted means from the Poisson model demonstrated significant improvement over time (P <.001). Mean implementation of MOUD milestones ranged from 23% to 40% at baseline and grew to 84% to 93% by the end of the program (P <.001). This model supported primary care practices that were initially doing little to no MOUD prescribing, to prescribe at significantly higher levels by the end of the program. This scalable model for addiction consultation in primary care settings illustrates how education and support to clinical teams can help practices makes changes, especially those with limited MOUD experience.

Association of Perioperative Glucagon-like Peptide-1 Receptor Agonist Use and Postoperative Outcomes.

To assess rates of surgical complications and postoperative readmission in diabetic patients with and without active perioperative prescriptions for GLP-1 RA medications. With the rapid growth of glucagon-like peptide-1 receptor agonist (GLP-1 RA) use in the United States, it is important to understand the potential effect of these drugs on surgical outcomes broadly. In this retrospective, observational cohort analysis, patients with a diagnosis of type 1 or type 2 diabetes undergoing a surgical procedure at a multicenter quaternary-care healthcare system between February 2020 to July 2023 were included. Propensity score matching was performed between procedures in patients with and without an active GLP-1 RA prescription. The primary outcome was 30-day readmission, and secondary outcomes were documented dehiscence, infection, hematoma, and bleeding within 180 days after surgery. Among 74,425 surgical procedures in 21,772 patients included in the analysis, 27.2% were performed in the setting of an active GLP-1 RA prescription. 35,020 procedures in 13,129 patients (48.0% men, 52.0% women; median [IQR] age, 67 [57, 75]) were propensity score matched. After matching, the active GLP-1 RA prescription group had a significantly reduced risk of 30-day readmission (RR, 0.883; 95% CI, 0.789-0.987; P=0.028; NNT, 219; 95% CI, 191-257), postoperative wound dehiscence (RR, 0.711; 95% CI, 0.577-0.877; P=0.001; NNT, 266; 95% CI, 202-391), and postoperative hematoma (RR, 0.440; 95% CI, 0.216-0.894; P=0.023; NNT, 1786; 95% CI, 652-2416). No significant differences were seen in rates of infection and bleeding. An active perioperative GLP-1 RA prescription in patients with diabetes was associated with significant reductions in risk-adjusted readmission, wound dehiscence, and hematoma, and no difference in infection and bleeding rates. Further study is warranted to elucidate any causal association.

Individualized Physical Activity Prescriptions for Children and Adolescents With Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

For improved health outcomes, children and adolescents with cancer must maintain physical activity. Individualized physical activity prescription is an effective way to promote physical activity in this group. We reviewed and meta-analyzed evidence on the effectiveness of individualized physical activity prescriptions for improving physical activity and other health outcomes among children and adolescents with cancer. Seven databases were searched from inception up to January 2024 for randomized controlled trials. Two researchers independently extracted data and assessed the quality of studies using the Risk-of-Bias tool. Data were pooled into Review Manager 5.3 for data synthesis and subgroup analyses. Seventeen randomized controlled trials were included. The systematic review summarized the characteristics of recent interventions. Meta-analyses showed that although individualized physical activity prescriptions had no overall effect on physical activity (n = 8 studies), anthropometry and body composition (n = 5), functional capacity (n = 3), quality of life (n = 8), fatigue (n = 3), and self-efficacy (n = 5), they improved cardiovascular fitness (n = 8, P = .02) and muscle strength (n = 8, P = .04). Subgroup analyses showed that studies providing 6-month interventions (P = .003) or such interventions combined with motivational interviewing (P = .002) reported significantly increased physical activity in patients. Individualized physical activity prescriptions appear to improve cardiovascular fitness and muscle strength in children and adolescents with cancer. High-quality studies providing long-duration interventions and motivational interviewing are needed for optimal physical activity programs for children and adolescents with cancer. The application of electronic devices should increase the types of physical activities for this group to further improve health outcomes.

Arthritis Management: Patient-Reported Health Care Provider Screening, Counseling, and Recommendations for Physical Activity.

Little is known about the recency, correlates, and content of health care provider (HCP) counseling about physical activity (PA) among adults with arthritis. We analyzed data from the Porter Novelli FallStyles cross-sectional survey of noninstitutionalized US adults. Among adults with arthritis, we assessed the recency of HCP counseling about PA; counseling content, including PA assessment/screening and advice/counseling; and recommendations. Data were weighted by sex, age, household income, race and ethnicity, household size, education, census region, and metropolitan status. Among adults with arthritis (n = 1,113), 16.8% received HCP counseling within the past 6 months, 9.6% received counseling between 6 months and a year ago; 27.7% received HCP counseling more than a year ago; 30.4% never received HCP counseling; and 15.5% did not recall. Prevalence of HCP counseling about PA was higher for those reporting obesity (prevalence ratio [PR] = 1.3) and chronic pain (PR = 1.2), compared with those without these conditions. The most and least common content of HCP counseling were assessment of PA level (74.7%) and receiving a physical activity prescription (6.1%), respectively. The most frequent recommendations for PA type were flexibility exercises (40.1%), aerobic activities (39.8%), specific modalities of PA (eg, swimming, walking, dancing; 38.1%), and muscle-strengthening exercises (36.6%). Only 4.4% received a recommendation for arthritis-appropriate PA programs. HCP counseling about PA among adults with arthritis for arthritis symptom management is lacking in frequency, actionable content, and recommendations to engage in evidence-based PA interventions. Dissemination and implementation of policies and programs facilitating frequent high-quality HCP counseling and recommendation to PA programs for arthritis remains a public health priority.

Automated Text Message-Based Program to Improve Uncontrolled Blood Pressure in Primary Care Patients: A Randomized Clinical Trial.

Suboptimal control of BP is common, although safe and effective treatments are widely available. Conventional management relies on office visits, but this can be an inefficient path to medication optimization. To assess the effectiveness of an intensive, 6-month remote BP management program among patients with uncontrolled hypertension. A two-arm randomized clinical trial which ran from January to July 2023 at two primary care practices with an in-clinic BP measurement at the end of the intervention. Established adult patients (ages 21-80) of study practices with uncontrolled hypertension (two measurements > 140/90 in the prior 12months) and an active prescription for at least one anti-hypertensive agent. Participants received automated text messages prompting them to check their BP weekly for 6months. An RN and APP monitored BP data entered by the participant. The automated platform escalated any out-of-normal range readings or needs to the program staff. The primary outcome was change in SBP from baseline to the end-of-study measurement. Enrollment and engagement measures were collected for the intervention arm. Of the 300 participants, the mean (SD) age was 63 (± 12.2) years; 133 (44.3%) were male and 167 (55.7%) were female; 154 (51.5%) self-identified as Black and 120 (40.1%) White; and 119 (39.7%) were insured by Medicare and 41 (13.7%) by Medicaid. The change in SBP at 6months among those who completed the end-of-study measurement was - 14.66mmHg (95% CI - 19.95, - 9.36) in the intervention arm and - 10.87mmHg (95% CI - 18.04, - 3.69) in the control arm (p = 0.39). Within the intervention arm, 97 participants (64.7%) completed all enrollment steps, and these participants submitted BPs 72.8% of the weeks. Participants in the intervention arm had a greater number of medication changes (0.81 vs 0.57 in the control arm, p = 0.01) over the study period. In this randomized clinical trial of a 6-month automated text messaging program, there was no significant difference in the change in SBP among participants in each arm. ClinicalTrials.gov Identifier: NCT05571410.

Improving Proton-Pump Inhibitor Adherence Intervention Between Primary Care and Community Pharmacies: A Pre-Post Intervention Study.

Proton-pump inhibitor (PPI) therapy stands as the primary treatment for upper gastrointestinal symptoms, yet poor adherence often results in treatment failure. Given that patients experiencing these symptoms frequently seek assistance at community pharmacies, the development of collaborative tools with primary care is becoming imperative. The objective was to assess the effectiveness of a pharmaceutical intervention, as demonstrated by a collaborative model between primary care and community pharmacies, in enhancing adherence to PPI among patients experiencing upper gastrointestinal symptoms. A Pre-post intervention study was carried out in Spanish community pharmacies (June-October 2022). During the baseline visit, patients' sociodemographic and clinical variables were evaluated. Patients were categorized as adherent or non-adherent using the Morisky Medication Adherence Scale (MMAS-4). In the follow-up visit (14 days later), the impact of the intervention was measured by changes in the Gastroesophageal Reflux Disease Impact Scale (GIS). Of the 351 patients with an active PPI prescription, 178 (50.7%) were non-adherent. Nearly 70% of these patients (122, 68.5%) received an intervention to improve adherence. The overall GIS score improved after the intervention (mean 25.34, SD 5.66 vs mean 27.64, SD 5.63, p < 0.001). All GIS score items showed improvement after the intervention except for the item regarding the taking of additional medication different from that prescribed by the clinician (p = 0.200). The pharmaceutical intervention had a positive impact on patients' symptom relief and overall quality of life, highlighting the significance and efficacy of a collaborative model between primary care and professional pharmaceutical services. Clinical Trial Registration (NCT05162079).

Student and physiotherapists' perceived abilities to prescribe effective physical activity and exercise interventions: A cross-sectional survey.

Physical activity, aerobic and resistance training have established benefits to health and wellbeing, with physiotherapists playing a vital role in their promotion. To capture UK student and graduate physiotherapists (1) knowledge of accepted guidelines and, (2) perceptions of physical activity and exercise prescription in practice. National cross-sectional online survey. A survey was conducted online among UK student and graduate physiotherapists from July to December 2021. Quantitative questions included dichotomous (yes/no), multiple-choice, and Likert scale (1-5) formats, alongside open-ended qualitative questions. Of 305 respondents (18% students, 47%>10 years' experience), 295 (97%) either "agreed" (n=64, 21%) or "strongly agreed" (n=231, 76%) that physical activity was a part of their role. Less than half felt the physiotherapy profession was able to provide effective physical activity (n=149, 49%, 95% confidence intervals 43 to 54) and aerobic training (130, 43%, 37 to 48). Most knew the weekly minimum adult dosage of physical activity (257, 84%, 80 to 88) and resistance training (267, 88%, 83 to 91) but were generally unable to correctly identify aerobic and resistance training guidelines. Of those who used evidenced based guidelines regularly with patients 72% were not adopting correct guidelines for aerobic (n=58, 72%, 61 to 80) and 46% for resistance training (n=45, 46%, 36 to 56). Limited patient appointment duration, inadequate access to facilities and a lack of continuous professional development opportunities were perceived barriers to implementation. Respondents agreed physical activity and exercise are vital treatment modalities, however many lack the knowledge to deliver these interventions in line with contemporary guidelines.

Gender-Affirming Hormone Therapy Is Associated with Increased Odds of Screening for Sexually Transmitted Infections in a Clinical Cohort of Transgender and Nonbinary Adults.

Transgender and nonbinary adults (TNB) are disproportionately burdened by sexually transmitted infections (STI) and the human immunodeficiency virus (HIV). This study investigated whether gender-affirming hormone therapy was associated with TNB adults' odds of screening for STI and HIV. Longitudinal data came from the electronic medical records of TNB primary care patients receiving care at two community health centers located in Boston, Massachusetts, and New York City, New York, between January 2013 and December 2019. Missing data were addressed using multiple imputation with chained equations, and statistical analyses included the use of unadjusted and covariate-adjusted logistic generalized estimating equation models. Models examined whether gender-affirming hormone therapy was significantly associated with patients' concurrent odds of STI and HIV screening between 2016 and 2019 (i.e., patients screening within the same year they had an active hormone prescription). Gender-affirming hormone therapy was associated with statistically significant higher odds of STI screening (chlamydia and gonorrhea), but not HIV screening, among TNB patients (STI screening: adjusted odds ratio [aOR] = 1.25, 95% confidence interval [CI] = [1.05, 1.49]; HIV screening: aOR = 1.21, 95% CI = [1.00, 1.47]). Additionally, taking preexposure prophylaxis (PrEP) for HIV prevention was associated with increased odds of both STI and HIV screening (STI screening: aOR = 3.74, 95% CI = [1.82, 7.71]; HIV screening: aOR = 4.41, 95% CI = [2.25, 8.64]). Primary care appointments for the provision of gender-affirming hormones may be an opportune time to incorporate routine STI/HIV screening for sexually active TNB patients. The provision of gender-affirming hormone therapy and PrEP may increase patients' odds of routine STI/HIV screening.

Redefining low-threshold buprenorphine access in an integrated mobile clinic program: Factors associated with treatment retention

IntroductionThe Spot mobile clinic provides low-threshold buprenorphine integrated with clinical and social services in Baltimore City, MD. In 2021, The Spot modified practices to improve engagement including providing extended prescriptions, reducing frequency of toxicology testing, giving up to six months to stabilize on medication, offering maximum doses (up to 32 mg total) daily, and utilizing telemedicine. This study characterizes care retention by examining both the total time in care and the percentage of time with buprenorphine prescription coverage during these practice changes, and examines factors associated with retention. MethodsThis retrospective cohort study includes patients (n = 341) who received a buprenorphine prescription who initiated care on The Spot mobile clinic from September 2021 to October 2022, with follow-up through October 2023. We utilized the Cox proportional hazards model and Kaplan-Meier survival analyses to assess differences in care retention by the factors of patient demographics and clinical characteristics. Additionally, we performed sensitivity analyses using Poisson regression to examine differences between patients with 80 % or greater time with active prescription coverage versus <80 % of time with active prescription coverage. ResultsAfter practice setting changes, retention in care at 90 days was 60 %. Patients whose maximum daily buprenorphine dose was 28 to 32 mg were 80 % less likely to discontinue treatment over the study period than those prescribed ≤16 mg (adjusted hazard ratio of discontinuation: 0.2 [95 % CI: 0.1–0.3]). Engaging in wound care or hepatitis C treatment was associated with higher retention in care, and individuals experiencing homelessness remained engaged at rates comparable to stably housed patients. ConclusionPractice changes aimed to improve access to patient-centered, low-threshold buprenorphine treatment may increase retention in care. Notably, higher doses of buprenorphine and integrated treatment with wound care and hepatitis C treatment were associated with increased retention. Due to gaps in patient care, retention metrics should incorporate total time in care as well as percentage of time with an active buprenorphine prescription.

Integrating genome-wide information and wearable device data to explore the link of anxiety and antidepressants with pulse rate variability.

This study explores the genetic and epidemiologic correlates of long-term photoplethysmography-derived pulse rate variability (PRV) measurements with anxiety disorders. Individuals with whole-genome sequencing, Fitbit, and electronic health record data (N = 920; 61,333 data points) were selected from the All of Us Research Program. Anxiety polygenic risk scores (PRS) were derived with PRS-CS after meta-analyzing anxiety genome-wide association studies from three major cohorts- UK Biobank, FinnGen, and the Million Veterans Program (NTotal =364,550). PRV was estimated as the standard deviation of average five-minute pulse wave intervals over full 24-hour pulse rate measurements (SDANN). Antidepressant exposure was defined as an active antidepressant prescription at the time of the PRV measurement in the EHR. Anxiety PRS and antidepressant use were tested for association with daily SDANN. The potential causal effect of anxiety on PRV was assessed with one-sample Mendelian randomization (MR). Anxiety PRS was independently associated with reduced SDANN (beta = -0.08; p = 0.003). Of the eight antidepressant medications and four classes tested, venlafaxine (beta = -0.12, p = 0.002) and bupropion (beta = -0.071, p = 0.01), tricyclic antidepressants (beta = -0.177, p = 0.0008), selective serotonin reuptake inhibitors (beta = -0.069; p = 0.0008) and serotonin and norepinephrine reuptake inhibitors (beta = -0.16; p = 2×10-6) were associated with decreased SDANN. One-sample MR indicated an inverse effect of anxiety on SDANN (beta = -2.22, p = 0.03). Anxiety and antidepressants are independently associated with decreased PRV, and anxiety appears to exert a causal effect on reduced PRV. Those observational findings provide insights into the impact of anxiety on PRV.

Music to Their Ears: Reducing Antipsychotic Use With a Personalized Music Intervention for Rural Veterans.

Background This project investigates a music intervention to deprescribe antipsychoticsin rural Veterans with dementia. Methods The Veterans Health Administration Home-Based Primary Care Program is care provided in the home by an interdisciplinary team with the goals of decreasing hospitalizations and falls, providing education to patients and caregivers, and improving quality of life. Eighteen Home Based Primary Care Veterans with dementia and active antipsychotic prescriptions were identified with the goal to deprescribe antipsychotics in 50% of them using a music intervention. Individualized playlists and assessments for Veteran quality of life and caregiver burden were evaluated. Phone visits tracked music utilization and captured the voice of the customer. Results Antipsychotic dose reduction occurred in five of eight Veterans, totaling eight dose reductionsand one discontinuation. Veteran quality of life improved; however, caregiver burden increased initially. The caregiver burden did improvewhen an outlier was removed. The voice of the customer favored music intervention. Conclusions A personalized music intervention is a feasible approach for reducing antipsychotic use in rural Veterans, improving quality of life, and potentially reducing caregiver burden.

Statin Therapy is Associated With Lower Risk of Mortality Among Liver Transplant Candidates With Metabolic Dysfunction-associated Steatohepatitis

BackgroundStatin therapy is historically underutilized in patients with chronic liver disease. There is increasing evidence to support the use of statins in patients with cirrhosis, though data in decompensated patients are limited. The primary aim of this study was to evaluate the association between statin use and mortality in patients with advanced liver disease, comparing MASH and non-MASH cirrhosis. MethodsThis single-center retrospective cohort study included patients undergoing liver transplant (LT) evaluation at a large quaternary care center. Patients were categorized by etiology as metabolic dysfunction-associated steatohepatitis (MASH) or non-MASH cirrhosis. Statin use was defined as having an active prescription at the time of LT evaluation. The association between statin use and mortality was evaluated using multivariable Cox proportional hazard regression. ResultsThe study included 623 patients; 24% had MASH cirrhosis and 20% were prescribed a statin. Statin users were older, had a higher BMI and were more likely to have coronary artery disease. At the end of the study, statin use was associated with lower mortality among MASH patients (16% vs. 35%, p=0.010) and higher mortality among non-MASH patients (31% vs. 19%, p=0.066). After controlling for age (HR 1.05, 95% CI 1.00 – 1.10, p=0.039), MELD-Na (HR 1.07, 95% CI 1.04 – 1.11, p<0.001), BMI (HR 1.09, 95% CI 1.05 – 1.14, p<0.001), and CAD (HR 1.20, 95% CI 0.54 – 2.69, p=0.653), statin use conferred a 53% lower risk of death compared to no statin use in patients with MASH cirrhosis (HR 0.47, 95% CI 0.22 – 0.98, p=0.043). ConclusionsStatin use was associated with reduced mortality in patients with decompensated MASH cirrhosis undergoing LT evaluation, but increased mortality in those with non-MASH cirrhosis, particularly those with high-MELD-Na. These findings underscore the importance of reviewing individual patient characteristics and disease etiology when considering the benefits of statin therapy in patients with cirrhosis.

Environmental Outcomes of Reducing Medication Waste by Redispensing Unused Oral Anticancer Drugs

Medications are associated with substantial environmental outcomes, yet frequently end up being unused by patients. Waste-minimizing interventions, such as redispensing of quality-approved oral anticancer drugs remaining unused by patients at home, could reduce the environmental footprint of cancer treatment. To assess the environmental outcomes of redispensing quality-assured oral anticancer drugs and to explore how redispensing could be environmentally optimized. In this quality improvement study, a cradle-to-grave life cycle assessment was performed in the outpatient pharmacy of 4 Dutch hospitals, based on a prospective multicenter trial comprising 1071 patients with a clinical diagnosis of cancer and an active prescription for an oral anticancer drug stored at room temperature from February 1, 2021, to February 1, 2023, with a follow-up of 12 months per patient. Participants received prescribed oral anticancer drugs with additional quality-assurance materials (ie, seal bags and time-temperature indicators), so the pharmacy could redispense quality-assured drugs based on authenticity, appearance, remaining shelf life, and/or adequate storage. The estimated environmental outcomes avoided due to waste reduction (ie, production and transport and incineration of redispensed oral anticancer drugs) corrected for outcomes of process burdens (ie, quality assurance materials), quantified in 3 outcome measures: human health damage (disability-adjusted life-years), ecosystems damage (species × year), and climate change (kg of carbon dioxide equivalent [CO2-eq]) per patient per year. A volunteer sample of 1071 patients (median age, 70 years [IQR, 62-75 years]; 622 men [58.1%]) participated in the intervention. Redispensing oral anticancer drugs was initially associated with an environmental burden, mainly because of the high impact of time-temperature indicators. However, when quality-assurance materials were selectively used for temperature-sensitive oral anticancer drugs (ie, maximum storage temperature of 25 °C), redispensing was environmentally beneficial to human health and ecosystems, providing estimated climate benefits of 1.9 kg (95% CI, 1.4-2.6 kg) of CO2-eq per patient per year. In this quality improvement study, redispensing unused oral anticancer drugs was found to be a suitable strategy to reduce waste and improve environmental sustainability of cancer treatment after process optimization. Redispensing unused oral anticancer drugs could contribute to sustainability of cancer treatment through reduced costs and environmental outcomes.

5158 Estrogen for Feminizing Gender Affirming Hormone Therapy: Understanding the Influence of Route of Administration and Dose on Serum Estradiol and Testosterone Levels

Abstract Disclosure: D.J. Slack: None. A. Di Via Ioschpe: None. M. Saturno: None. S. Kihuwa-Mani: None. U. Amakiri: None. S. Karim: None. D. Guerra: None. J.D. Safer: None. For feminizing gender affirming hormone therapy (GAHT), the Endocrine Society and WPATH SOC 8 suggest targeting testosterone (T) levels below 50 ng/dL and estradiol (E2) levels in the range of 100-200 pg/mL. Exogenous estrogen may be given via several routes of administration (ROA) and at a variety of doses, but little is known about how ROA and dose influence T and E2 levels. We sought to investigate the relationship between estrogen dosage, ROA, and hormonal profiles in trans feminine individuals. We conducted a chart review of patients in the Mount Sinai Health System and included all patients who had active prescriptions for feminizing GAHT with both T and E2 levels recorded (n = 585), excluding those with a history of orchiectomy. For oral (PO) estrogen, there was a negative correlation between dose and serum T (p &amp;lt; .01), LH (p &amp;lt; .05), and FSH (p &amp;lt; .05), but no correlation with E2. For transdermal (TD) estrogen, dose did not correlate with serum T, E2, LH, or FSH. For intramuscular (IM) estrogen, there was a positive correlation with serum E2 (p &amp;lt; .05), LH (p &amp;lt; .05), and FSH (p &amp;lt; .01), but no correlation with T. Individuals were then stratified into groups of T and E2 ranges that were determined via bell-curve frequency distributions. Within each group, the relative proportion of users of a given ROA, their mean dose of estrogen given via that ROA, and their resulting mean T and E2 levels were calculated. For users of IM estrogen, a significantly higher proportion of individuals had T &amp;lt; 50 ng/dL as opposed to T &amp;gt;= 50 ng/dL. IM users also much more frequently exhibited E2 &amp;gt;= 200 pg/mL than E2 &amp;lt; 200 pg/mL. For users of PO estrogen, a higher proportion of individuals had T &amp;gt;= 100 ng/dL compared to T &amp;lt; 50 ng/dL, with the proportion of those with T 50-99 ng/dL not differing from either group. A higher proportion of users of PO estrogen had E2 50 - 199 pg/mL compared to E2 &amp;lt; 25 ng/dL and E2 &amp;gt; 200 pg/mL, with the proportion of those with E2 25-49 pg/mL not differing significantly from either. For users of TD estrogen, there was a higher proportion of those with T 50 - 99 ng/dL compared to &amp;lt; 50 ng/dL and &amp;gt;= 200 ng/dL, with the proportion of those with T 100 - 199 ng/dL not differing from either group. A higher proportion of users of TD estrogen had E2 25 - 49 pg/mL compared to E2 100 - 199 pg/mL and E2 &amp;gt; 300 pg/mL, while the frequency of those with E2 &amp;lt; 25 pg/mL, 50 - 99 pg/mL, or 200 - 299 pg/mL did not differ significantly. Our results indicate a propensity for users of IM estrogen to achieve T suppression and to overshoot E2 targets, while users of PO estrogen were most likely to have E2 levels at-target but less likely to achieve T suppression. Users of TD estrogen appear least likely to achieve either target. While further research is needed to confirm and expand upon our findings, our data are an important step forward in providing clinicians with some predictive capability as to the serum E2 and T levels they might expect with the use of exogenous estrogen at a given dose and ROA. Presentation: 6/2/2024