Significant Reduction In Rate Research Articles

305.1: Effect of language and country of birth of potential donors on organ donor outcomes; a data-linked cohort study from New South Wales, Australia 2010-2015.

Background: A growing proportion of referred donors in Australia do not donate despite significant unmet need for transplantation. Australia is culturally diverse with 30% population born overseas. We sought to assess the impact of donor cultural and linguistic diversity (CALD) on family consent and on medical suitability for organ donation. Methods: We conducted a retrospective observational cohort study from the New South Wales (NSW) Biovigilance Public Health Register (SAFE-BOD), including all organ donor referrals in NSW 2010-2015. Outcomes of interest were families being asked for consent to donation, families providing consent for donation, and the donor being deemed medically suitable for donation. Impact of primary language other than English and birthplace outside Australia were assessed with logistic regression. Results: There were 2,383 referrals eligible for donation and included in the analysis. Family consent was sought for 1,302 and was granted for 846 referrals. There were 991 referrals medically suitable for donation. There was no difference in consent seeking from families of non-English speakers compared to English speakers (p=0.07) or those born overseas compared to those born in Australia (p=0.3, Figure One). However, families of non-English speakers were less likely to give consent than families of English speakers (OR 0.44, p<0.001), and similarly referrals born overseas had families who were less likely to consent than other referrals (OR 0.54, p<0.001). The combined effect of being non-English speaking and born overseas led to a significant reduction in rates of family consent being sought compared to other referrals (OR 0.67, p=0.01). There was no difference in medical suitability between English speakers or non-English speakers (p=0.6), Australian born or overseas-born referrals (p=0.6). Conclusions: Culturally and linguistically diverse referrals were less likely to obtain family consent to donation. There was no difference in medical suitability, but suggestion that consent may be sought less from CALD families. Ongoing focus to improve consent rates from CALD communities may help overall donation rates.

1174. The Impact of Multidisciplinary Central Line Stewardship Program to Decrease CLABSI Rates and Central Line Utilization Rates in an Academic Urban Medical Center

BackgroundCentral Line-Associated Blood Stream Infections (CLABSI) is a major healthcare dilemma, contributing to increased morbidity, mortality, and costs. We sought to reduce rates of CLABSI and device utilization by implementing a multidisciplinary Central Line Stewardship Program (CLSP).MethodsIn July 2017, the CLSP, multidisciplinary quality improvement project, was implemented at an academic medical center to ensure proper indication for all CVCs in the hospital and removal when no longer indicated. A CLSP team of executive leaders and infection preventionists performed daily rounds on all CVCs to review indications and maintenance. Nursing staff reported all CVCs daily. Information Technology modified the electronic health record to require daily physician documentation of CVC placement and indications, and to suggest alternatives to CVC when possible. In the event of a CLABSI, a root cause analysis was conducted within 72 hours, and feedback was shared with the clinical staff. A retrospective review was conducted 18 months before and after CLSP implementation. As a facility in a state with mandatory reporting of hospital-acquired infections, institutional data were readily available through the National Healthcare Safety Network (NHSN). To compare rates of CLABSI and device utilization pre- and post-CLSP, we reviewed the Incidence Density Rate (IDR), the standardized infection ratio (SIR), and standardized utilization ratio (SUR). Data from the NHSN website were analyzed using statistical tools provided by the NHSN analysis module. Two-tailed significance tests were conducted with α set at 0.05.ResultsPost-CLSP, there was a statistically significant decrease in SIR from 1.99 to 0.885, with risk reduction by 44.3% (P = 0.013, 95% CI 0.226 -0.831). CLABSI IDR per 1000 CVC days declined from 1.84 to 0.886 (P = 0.0213). CVC utilization per 1000 patient-days reduced from 155.08 to 142.35 (P < 0.001). There was also a trend toward fewer PICC line infections post-intervention (17 to 5).ConclusionWith this novel CLSP, we achieved a significant reduction in rates of CLABSI and device utilization, suggesting that a multidisciplinary approach can promote sustainable prevention of line-associated infections through dedicated surveillance of CVC indications and maintenance. Disclosures All authors: No reported disclosures.

1108. Impact of Implementing a Urine Culture Order Set on Antibiotic Utilization and Rates of Catheter-Associated Urinary Tract Infections in an Urban Academic Medical Center

BackgroundOverutilization of urine cultures may lead to inappropriate use of antibiotics. We implemented a computerized urine culture order set where urine specimens are not processed for culture unless there is evidence of pyuria (≥10 WBC per high power field) on urinalysis (UA), or if a patient is pregnant, neutropenic, neonate, renal transplant recipient, planned for or had a recent urologic procedure. Here we evaluated the impact of this order set on antibiotic utilization, urine culture volumes and rates of catheter-associated urinary tract infections (CAUTI).MethodsWe performed a retrospective chart review before and after the order set implementation (August–December 2017 and 2018, respectively). The analysis had two distinct components: first was at institution-level, where data for all adult and pediatric inpatients were compared for urine culture volumes and antibiotic use regardless of indication. The second component was done at patient-level, where we compared clinical data and days of therapy (DOT) for all adult inpatients who had urine cultures without pyuria in the specified pre-intervention period, and those with canceled urine cultures due to absence of pyuria post-intervention.ResultsAt the institution-level analysis, a statistically significant reduction was observed in rates of urine cultures performed (P = 0.02), as well as use of penicillins, carbapenems and Trimethoprim-Sulfamethoxazole (TMP-SMX) (P < 0.05). However, the use of cephalosporins has increased post-intervention (P < 0.001). No significant change was noted for aminoglycosides or fluoroquinolones.At the patient-level analysis, DOT means in patients with negative pyuria did not change significantly (5.16 pre-intervention, 6.54 post-intervention, P = 0.202). Prevalence of treatment for bacteriuria despite absence of pyuria was 5.3% (20/380) pre-intervention, vs. 1.9% (1/53) post-intervention (P = 0.494). In the pre-intervention period, three cases met the criteria for CAUTI despite negative pyuria. This misdiagnosis could have been avoided by implementation of the urine culture order set.ConclusionImplementation of a urine culture order set in our institution led to a statistically significant reduction in rates of urine cultures performed, as well as use of penicillins, carbapenems and TMP-SMX. Disclosures All authors: No reported disclosures.

Centrifuge model studies on the performance of soil walls reinforced with sand-cushioned geogrid layers

This paper is to investigate the effectiveness of encapsulating geogrid layers within thin sand layers, for enhancing the deformation behavior of vertical reinforced soil walls constructed with marginal backfills. Centrifuge model tests were performed on vertical soil walls, reinforced with geogrid layers, using a 4.5 m radius large beam centrifuge available at IIT Bombay at 40 gravities. The backfill conditions, height of soil wall, reinforcement length, and reinforcement spacing, were kept constant in all the tests. A wrap-around technique was used to represent flexible facing. Three different geogrid types with varying stiffness were used in the present study. The walls were instrumented with vertical linear variable differential transformers to monitor surface settlements during the tests. Marker-based digital image analysis technique was used to determine face movements and distribution of geogrid strain along the wall height. The deformation behavior of soil walls, reinforced with geogrid layers encapsulated in thin layers of sand, were compared against a base model having no sand-cushioned geogrid layers. Provision of sand-cushioned geogrid layers and increase in geogrid stiffness were found to limit normalized face movements (Sf/H), normalized crest settlements (Sc/H), and change in maximum peak reinforcement strain (dεpmax). Sand-cushioned geogrid layers were also found to limit the development of tension cracks behind and within the reinforced zone. Significant reduction in rate of maximum face movement (dSfmax/dt) and rate of maximum peak reinforcement strain (dεpmax/dt) was observed, with an increase in value of normalized reinforcement stiffness (Jg/γH2) of geogrid layers. The analysis and interpretation of centrifuge model tests on soil walls, constructed with marginal backfills and reinforced with sand-cushioned geogrid layers, indicate that their performance is superior to the walls without sand-cushioned geogrid layers.

Left main percutaneous coronary intervention-Radial versus femoral access: A systematic analysis.

Debate still occurs of the benefits of transradial access (TRA) versus transfemoral access (TFA), especially for complex percutaneous coronary interventions. Recent data has shown equivalent efficacy and improved safety outcomes with TRA. To systematically review and perform a meta-analysis comparing procedural characteristics and clinical outcomes of TRA versus TFA in patients who underwent percutaneous coronary intervention (PCI) for left main (LM) disease. We conducted an electronic database search of all published data for studies that compared TRA with TFA in patients undergoing PCI of LM disease. Event rates were compared using the odds ratio (OR) as a measure of effect size. Random-effects models were used to account for interstudy heterogeneity. A total of 12 observational studies including 17,258 patients (TRA n = 7,971; TFA n = 9,287) were included. Compared to TFA, TRA was associated with a significant reduction in access site bleeding (OR = 0.11; 95% confidence interval [CI] = 0.04-0.26; I2 = 0%; p < .0001), major bleeding (OR = 0.44; 95% CI = 0.27-0.69; I2 = 0%; p = .0005) or any bleeding episode (OR = 0.43; 95% CI = 0.27-0.69; I2 = 12%; p = .0004). Rates of access site or vascular complications (OR = 0.26; 95% CI = 0.17-0.40; I2 = 0%; p < .00001) and in-hospital mortality (OR = 0.49; 95% CI = 0.31-0.79: I2 = 11%; p = .004) were also lower in the TRA group. There were no significant differences in procedural outcomes between TRA and TFA except for a significant reduction in the rate of long-term target vessel revascularization (TVR) in the TRA group (OR = 0.62; 95% CI = 0.41-0.94: I2 = 0%: p = .02). We further performed a subgroup analysis for unprotected left main PCI only, which showed a significant reduction in rates of any bleeding episode, lower access site or vascular complications, and in-hospital mortality with TRA as compared to TFA. Patients undergoing PCI for LM disease via TRA have with less bleeding, reduced access site or vascular complications, reduced in-hospital mortality, comparable procedural success, and possibly better long-term clinical efficacy when compared to those undergoing the procedure via TFA.

Reducing risky driving: Assessing the impacts of an automatically-assigned, targeted web-based instruction program

Introduction: Transportation safety research has consistently shown driver behavior is the primary cause in the majority of crashes. This study evaluated the effectiveness of an automatically-assigned, targeted web-based instruction program to reduce risky driving behavior. Method: This quasi-experiment used a within-subjects, multiple-baseline stepwise ABC design; where “A” was the Phase I baseline, “B” was the Phase II driver awareness of program, and “C” was the Phase III WBI program. Results: A significant reduction in rates of risky driving behaviors coincided with the implementation of the WBI program, even for those drivers who did not receive WBI but were included in the program. More specifically, excessive speeding was significantly reduced by 73.93% from baseline to intervention across all drivers. For those drivers who received WBI, the program coincided with statistically significant reductions in speeding, hard braking, and hard cornering. The first WBI course assigned and completed was the most impactful in reducing at-risk driving behavior. Conclusions: These results show that the automatically-assigned, targeted WBI program was an effective method in reducing risky driving behaviors, not only for those drivers that received training, but for all drivers. The authors hypothesize the reduction in risky driving behaviors was not the result of the WBI, but instead from the implicit feedback of being assigned a training courses, the development of implicit, non-specific goals to reduce risky driving behaviors that result in a WBI course assignment, and the resulting increased driver accountability created by the WBI program. Practical application: Through the use of an automatically-assigned, targeted WBI program, fleets may have fewer crashes and insurance claims. This reduction in crashes and insurance claims may result in lower insurance premiums and may help to prevent injuries and save lives.

Precarity and the HIV/AIDS pandemic in the Caribbean: Structural stigma, constitutionality, legality in development practice

ABSTRACTThe social stigma of sexual immorality is inscripted in constitutions, laws, and statutes in the Caribbean and justified and legitimated through references to Christian doxa. This induces forms of structural stigma through policies and practices of governance. I employ country comparisons to demonstrate the critical effect on rates of HIV/AIDS of structural stigma induced by these inscriptions in Caribbean countries. By comparing rates of HIV/AIDS across selected countries, I analyse the differing patterns of structural stigma against the latter’s relationship with structural vulnerabilities associated with poverty, underdevelopment, government incapacities, and population flows. I conclude that significant reductions in rates of prevalence can be achieved when social stigma is minimised or meliorated through effective government action or through the influence of external actors, even in the presence of other forms of structural vulnerabilities. The intensity of population flows into a country can also act independently to increase rates of prevalence, even in the face of reductions in structural stigma related to sexual immorality.

Non-Invasive Ventilatory Support In the Elderly.

The first description of non-invasive ventilation use began in the 1920s. Since then, its role in patient care has evolved through increased clinical knowledge and scientific advancements. The utilization of non-invasive ventilation has broadened from initial application in acute in-hospital ICU settings to now include the outpatient settings. This review discusses the history of non-invasive ventilation and its role in acute in-hospital chronic obstructive pulmonary disease (COPD) exacerbations, cardiogenic pulmonary edema, and weaning from mechanical ventilation in the elderly. The elderly population represents a significant portion of patients hospitalized for the aforementioned conditions. These groups often have more limitations related to the use of invasive mechanical ventilation (IMV), therefore, it is essential to understand the impact of non-invasive ventilation on hospital outcomes. There is strong clinical evidence supporting the use of non-invasive ventilation in patients with respiratory failure secondary to acute COPD exacerbations and cardiogenic pulmonary edema. When compared to standard medical management of these conditions, there is a consistent and significant reduction in the rate of endotracheal intubation and in-hospital mortality. The basis of noninvasive ventilation applicability has been determined by significant reduction in mortality and intubation rates. Although survival benefits have been observed, there still remain limitations to the clinical applicability of non-invasive ventilation in certain patient populations and conditions that require further investigation.

Influence of post-condensation on the crystallization kinetics of PA12: From virgin to reused powder

The effect of prolonged storage at elevated temperatures on the isothermal crystallization kinetics of Polyamide 12 (PA12), the most used polymer in selective laser sintering (SLS), has been studied by means of Flash DSC experiments. The experimental results are described and modelled with a full multi phase crystallization model which allowed us to estimate the growth and nucleation kinetics for every PA12 crystal phase. Virgin PA12 powder has been annealed at different temperatures for different times to quantify the molecular weight evolution due to post condensation. To check the effect of thermal treatments on the final viscosity, rheology measurements have been carried out. We show that thermal annealing results in a significant increase in molecular weight and viscosity which lead to a reduction of the crystallization rate in a limited temperature range. At very low temperature the crystallization kinetics, expressed in terms of peak-time of crystallization, appears to be independent on the annealing treatment while in the temperature range between 100∘C and 150∘C a significant rate reduction is observed. We demonstrate that the crystallization kinetics in this temperature range is governed by the crystal growth process, i.e. the increase in molecular weight due to post-condensation causes a reduction of the growth rate of the main crystalline phases of PA12, namely α' and γ-phase. Similar to the low temperature crystallization, at temperature higher than 150∘C the annealing does not noticeably affect the growth rates and the crystallization kinetics of virgin and annealed PA12 overlap. These results can provide a better insight of the effect of reusing PA12 powder in the SLS process.

Effect of Albuterol Premedication vs Placebo on the Occurrence of Respiratory Adverse Events in Children Undergoing Tonsillectomies

Tonsillectomy is a common pediatric procedure for the treatment of sleep-disordered breathing and chronic tonsillitis. Up to half of children having this procedure experience a perioperative respiratory adverse event. To determine whether inhaled albuterol sulfate (salbutamol sulfate) premedication decreases the risk of perioperative respiratory adverse events in children undergoing anesthesia for tonsillectomy. A randomized, triple-blind, placebo-controlled trial (the Reducing Anesthetic Complications in Children Undergoing Tonsillectomies [REACT] trial) was conducted at Perth Children's Hospital (formerly Princess Margaret Hospital for Children), the only tertiary pediatric hospital in Western Australia. Participants included 484 children aged 0 to 8 years who were undergoing anesthesia for tonsillectomy. The study was conducted between July 15, 2014, and May 18, 2017. Participants were randomized to receive either albuterol (2 actuations, 200 μg) or placebo before their surgery. Occurrence of perioperative respiratory adverse events (bronchospasm, laryngospasm, airway obstruction, desaturation, coughing, and stridor) until discharge from the postanesthesia care unit. Of 484 randomized children (median [range] age, 5.6 [1.6-8.9] years; 285 [58.9%] boys), 479 data sets were available for intention-to-treat analysis. Perioperative respiratory adverse events occurred in 67 of 241 children (27.8%) receiving albuterol and 114 of 238 children (47.9%) receiving placebo. After adjusting for age, type of airway device, and severity of obstructive sleep apnea in a binary logistic regression model, the likelihood of perioperative respiratory adverse events remained significantly higher in the placebo group compared with the albuterol group (odds ratio, 2.8; 95% CI, 1.9-4.2; P < .001). Significant differences were seen in children receiving placebo vs albuterol in laryngospasm (28 [11.8%] vs 12 [5.0%]; P = .009), coughing (79 [33.2%] vs 27 [11.2%]; P < .001), and oxygen desaturation (54 [22.7%] vs 36 [14.9%]; P = .03). Albuterol premedication administered before tonsillectomy under general anesthesia in young children resulted in a clinically significant reduction in rates of perioperative respiratory adverse events compared with the rates in children who received placebo. Premedication with albuterol should be considered for children undergoing tonsillectomy. Australian New Zealand Clinical Trials Registry identifier: ACTRN12614000739617.

Abstract P145: Outcomes of an EMR-Enabled Acute Ischemic Stroke Care Path in a Primary Stroke Center

Background: One major challenge in health care is to improve value, which is best measured at the disease or treatment level. Evidenced-based, standardized care has been proposed and studied as one potential method to drive this process. We hypothesize that enablement of the Acute Ischemic Stroke (AIS) Care Path within the electronic medical record (EMR) improves clinical outcomes of patients with acute ischemic stroke. Methods: We compared the length of stay (LOS), in-patient mortality, rate of hospital readmission within 30 days, NIH Stroke Scale (NIHSS) at admission in patients, and post-discharge modified Rankin Scale (mRS) with ischemic stroke in the periods before (January to December 2015) and after (January to December 2016) EMR-enablement of the AIS Care Path. Results: A total of 1,858 patients were diagnosed with acute ischemic stroke during the entire study period. Patients presented with more severe stroke symptoms, as evidenced by a higher NIHSS at admission in the post-intervention period (11.4 ± 0.7 vs 10.5 ± 0.7, p=0.05). There was no difference in LOS (5.2 ± 0.3 days vs 5.3 ± 0.2 days, p=0.41), and there was a significant reduction in rate of hospital readmission within 30 days of discharge (8.9 ± 2.0 vs 10.7 ± 2.0, p=0.05). There were trends toward decreased in-patient mortality (2.6 ± 0.7% vs 3.3 ± 1.5%, p=0.22) and improved functional outcomes (2.3 ± 0.3 vs 2.6 ± 0.4, p=0.20) after EMR-enablement of the AIS Care Path. Conclusion: EMR-enablement of the AIS Care Path, a means of further standardizing stroke care, was associated with lower readmission and trends toward lower mortality and improved functional outcomes.

Association of State Medicaid Expansion With Quality of Care and Outcomes for Low-Income Patients Hospitalized With Acute Myocardial Infarction

Lack of insurance is associated with worse care and outcomes among adults hospitalized for acute myocardial infarction (AMI). It is unclear whether states' decision to expand Medicaid eligibility under the Patient Protection and Affordable Care Act in 2014 were associated with improved quality of care and outcomes among low-income patients hospitalized with AMI. To investigate whether rates of uninsurance, quality of care, and outcomes changed among patients hospitalized for AMI 3 years after states elected to expand Medicaid compared with nonexpansion states. Retrospective cohort study completed at hospitals participating in National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry. Participants were patients younger than 65 years hospitalized for AMI from January 1, 2012, to December 31, 2016. State Medicaid expansion in 2014. Rates of uninsured and Medicaid-insured hospitalizations for AMI in states that expanded Medicaid vs those that did not. Comparison of in-hospital care quality, procedure use, and mortality between expansion and nonexpansion states for the years prior to and after Medicaid expansion. Hierarchical logistic regressions models were used to assess the association between Medicaid expansion and outcomes. The initial cohort included 325 343 patients. Uninsured AMI hospitalizations declined in expansion states (18.0% [4395 of 24 358 hospitalizations] to 8.4% [2638 of 31 382 hospitalizations]) and more modestly in nonexpansion states (25.6% [7963 of 31 137 hospitalizations] to 21.1% [8668 of 41 120 hospitalizations]) from 2012 to 2016 (P < .001 difference in trend expansion vs nonexpansion). Medicaid coverage increased from 7.5% (1818 of 24 358 hospitalizations) to 14.4% (4502 of 31 382 hospitalizations) in expansion states and 6.2% (1924 of 31 137 hospitalizations) to 6.6% (2717 of 41 120 hospitalizations) in nonexpansion states (P < .001). The low-income cohort included 55 737 patients across 765 sites. In expansion states, low-income adults' odds of receipt of defect-free care increased (76.3% to 75.9%, adjusted odds ratio 1.11; 95% CI, 1.02-1.21) but to a lesser degree than in nonexpansion states (72.8% to 74.5%, adjusted odds ratio, 1.38; 95% CI, 1.30-1.47; P for interaction < .001). There was no change in use of most procedures (ie, percutaneous coronary intervention for non-ST-segment elevation myocardial infarction) in expansion compared with nonexpansion states. Improvement in in-hospital mortality was similar between expansion and nonexpansion states (3.2% to 2.8%, adjusted odds ratio, 0.93; 95% CI, 0.77-1.12 vs 3.3% to 3.0%, adjusted odds ratio, 0.85; 95% CI, 0.73-0.99; P for interaction = .48). Medicaid expansion was associated with a significant reduction in rates of uninsurance among patients hospitalized with AMI. Quality of care and outcomes did not improve among low-income adults in expansion compared with nonexpansion states. Hospital care for AMI may be less sensitive to insurance than has been recognized in the past.

Review of Intravenous Amiodarone Administration to Reduce the Occurrence of Phlebitis

Background: Intravenous (IV) amiodarone is regularly administered at the current clinic unit for atrial fibrillation, including cardiology and post-cardiac surgery patients. The unit noted an increase in chemical phlebitis from the submission of reportable events. From this increase, a systematic review of administration was performed. Method: A literature review was performed of global administration guidelines – from the National Health Service, Australia, Canada and United States of America – and compared with current administration. The concentrations were similar but it was noted that IV giving sets were not filtered at the current centre. In partnership with IV therapy, correct filter IV giving sets were replaced. A retrospective review was then performed of patients, from the previous 3 months, who had received amiodarone via old IV giving sets and 3-month review was performed of new IV giving sets; chemical phlebitis rates were compared. Results: Aligning administration with international standards saw a reduction in phlebitis by 30%. There were no effects on cardioversion numbers due to increased filtration of drugs and no increased cost to the District Health Board for change of giving sets. Conclusion: Aligning administration guidelines with international standards enabled a significant reduction in rates of phlebitis. This reduced pain and infection risks for patients and reduced length of stay; thus, reducing the cost of treatment.

Effects of the storage of breast milk at different temperatures on total antioxidant capacity, total oxidant status, and paraoxonase-1 level.

Konak M, Minici M, Tarakçı N, Altunhan H, Toker A, Örs R. Effects of the storage of breast milk at different temperatures on total antioxidant capacity, total oxidant status, and paraoxonase-1 level. Turk J Pediatr 2019; 61: 1-6. Breast milk is a well-balanced ideal nutritional source with high bioavailability for infants. As being a fresh, biological and dynamic product, changes in the breast milk during these storage periods have been the subject of ongoing research. This study aims to evaluate total antioxidant capacity (TAC), total oxidant status (TOS), and paraoxonase-1 (PON-1) levels of fresh and freezestored breast milk. Ten cc of breast milk was obtained from the mothers as the days between 10 and 15 in the morning within a 1-hour period. TAC, TOS, and PON-1 levels were evaluated in the fresh breast milk. Collected breast milk samples were divided into two groups for storage at -20°C or -80°C. Stored samples were tested for TAC, TOS, and PON-1 levels after 72 hours. The highest TAC level was detected in fresh breast milk (p < 0.05). The TOS levels of fresh breast milk showed a statistically significant reduction in rate after storage. The TOS levels at -20°C and -80°C were significantly lower at -80°C (p < 0.05). Our study results show that oxidant and antioxidant activities are at the maximum level in the fresh breast milk. In terms of antioxidant status the effect of freezing temperatures hasn`t been determined. We conclude that it is more convenient to store the breast milk at -80°C than to store at -20°C in terms of preserving the storage TOS level.

A New and Detailed Assessment of the Spatiotemporal Characteristics of the SO2 Distribution in the Pearl River Delta Region of China and the Effect of SO2 Emission Reduction

ABSTRACT Signal enhancement technology (sub-pixel interpolation) is used to obtain SO2 column concentrations for Guangdong Province in China from 2005 to 2016. The high resolution (2 km × 2 km) data used was obtained via a remote sensing satellite (Ozone Monitoring Instrument) and verified by comparing it with average annual SO2 data recorded in ground monitoring stations. The correlation was found to be up to 0.95. Moreover, the data was cross-correlated with national and regional inventories of pollution sources. The results show that the regional characteristics of the spatial distribution obtained are consistent and the detailed characteristics are highly coincidental. Based on this, the new and detailed spatiotemporal variation was analyzed and the effect of emission reduction in urban agglomerations on the SO2 concentration in the Pearl River Delta (PRD) region of China investigated. The results demonstrate that the distribution of SO2 pollution in the PRD has been transformed over the period studied. In the early stages, it had a traditional high-concentration type of distribution (with agglomeration areas like Guangzhou and Foshan as high-concentration pollution centers) and this has changed to the currently-observed low-concentration decentralized type of distribution (mainly distributed along administrative boundaries). In the last 10 years, significant SO2 emission reduction has occurred in prefecture-level cities, e.g., Foshan, Zhongshan, and Guangzhou (with emission-reduction amplitudes of 71%, 65%, and 57%, respectively). Foshan and Zhongshan are the top two prefecture-level cities in the PRD region in terms of significant reduction in rate of SO2 contribution. The SO2 contribution rate fell from 17% to 13% in Foshan and from 16% to 10% in Zhongshan. However, the relative contribution rates in Zhaoqing and Huizhou increased from 7% to 11% and from 6% to 10%, respectively. The size of the emission reduction and changes in SO2 contribution rates in the prefecture-level cities in the PRD region show that the government’s efforts to improve air quality have had a significant effect.

A Meta-Analysis of Efficacy and Safety of Infliximab for Prevention of Postoperative Recurrence in Patients with Crohn's Disease.

Objective We sought to investigate the efficacy and safety of Infliximab for prevention of postoperative recurrence in patients with Crohn's disease (CD), in a meta-analysis of clinical trial results. Methods The Medline, Embase, PubMed, and Web of Science databases were systematically searched for suitable studies. A meta-analysis of enrolled studies was performed to analyze the efficacy of Infliximab on outcomes regarding the prevention of postoperative recurrence of CD. A Galbraith radial plot was used to quantify the heterogeneity. Funnel plot and Egger test were performed to describe the bias of publication. A Forest plot was prepared to indicate the efficacy outcomes. Results A total of 7 prospective trials were included in our meta-analysis (N=455). The Funnel plot and Egger test showed there was no significant bias in the included publications. The Cochrane collaboration tool indicated that all 7 prospective trials were of high quality. The results of Galbraith radial plot showed that no study was the source of heterogeneity. Compared with the placebo group, Infliximab decreased the rates of endoscopic recurrence (RR =0.421; 95% CI 0.328 to 0.539; p<0.001), and there was a significant reduction in rates of clinical recurrence in the Infliximab-treated group (RR =0.519; 95% CI 0.349 to 0.774; p=0.001). Furthermore, Infliximab treatment did not show adverse effects as other systematic therapeutic drugs, indicating that Infliximab treatment is effective and well tolerated. Conclusion Compared with the controls, Infliximab is a promising therapeutic agent for the management of CD patients.

Management of Mucositis with the Use of Leucovorin As Adjunct to Pralatrexate in Treatment of Peripheral T-Cell Lymphomas (PTCL) — Results from a Prospective Multicenter Phase 2 Clinical Trial

Background: A frequent complication of Pralatrexate therapy is development of oral mucositis. In a recent pivotal trial of pralatrexate (PROPEL, O'Connor et al. J Clin Onc 2011) the incidence of ≥ Grade 2 mucositis was 52%, occurring primarily in the first treatment cycle. Mucositis often leads to dose reduction or omission and possibly, diminished efficacy of pralatrexate in relapsed/refractory (R/R) PTCL. Leucovorin (d,l-folinic acid) is an approved rescue therapy for high-dose methotrexate (MTX) therapy, mitigating gastrointestinal lining, and bone marrow cell toxicity and has been used adjunctively with pralatrexate to manage mucositis. The objective of this prospective Phase 2, single-arm study was to evaluate the effect of leucovorin on the incidence of pralatrexate-induced mucositis in patients with R/R PTCL, including primary cutaneous T-cell lymphomas.Methods: Eligible patients had diagnosis of PTCL, including CTCL, confirmed by local hematopathologist or dermatopathologist and were deemed appropriate for pralatrexate therapy by investigator. Study treatment consisted of two cycles of Pralatrexate, (6 weekly doses (30 mg/m2) followed by 1 week of rest per cycle, currently approved label). All patients received vitamin B12 and folic acid supplementation; oral leucovorin, 25 mg TID was self-administered for 2 consecutive days (a total of 6 doses) beginning 24 hours after each dose of Pralatrexate. Patients underwent in-clinic oral mucositis assessment at baseline and at each visit prior to pralatrexate administration by healthcare professional. Patients also completed a daily oral mucositis questionnaire (OMDQ) from Day 1 of Cycle 1 to the end of treatment visit. Mucositis was assessed by the investigator and recorded as an AE along with grade and causality. Toxicities were assessed using Common Terminology Criteria (CTCAE V4.03). Responses were assessed by the investigator per revised Response Criteria for Malignant Lymphoma (Cheson 2007) and Modified SWAT Criteria for CTCL.The primary endpoint was the incidence of Grade 2 or higher oral mucositis in Cycle 1. Secondary endpoints included the incidence of ≥ Grade 3 mucositis, and overall response rate.Results: A total of 30 patients have been enrolled as of time of data analysis. The majority of patients were male, white, with the median age of 63 yrs (range, 31-85). To date (5 July 2018) 11 patients have completed the study treatment, 12 patients discontinued (1 AE, 9 PD, 1 death, and 1 withdrawal) and 7 patients remain in the trial. All 30 subjects reached the assessment of the primary endpoint. The primary endpoint of the study has been met. Twenty (67%) patients have reported TEAEs, of which 11 (37%) have been ≥Grade 3 AEs. Overall toxicity profile was consistent with previously reported in the PROPEL trial. Most common Pralatrexate-related AEs were fatigue in 6 (20%) patients and diarrhea that occurred in 4 (13%) patients. SAEs occurred in 9 patients (only pyrexia in >1 pt; N=2), none were treatment-related. The rate of ≥2 mucositis was 4% (95% C.I. = 0, 20%). No Grade 3 or higher mucositis occurred; Grade 1 mucositis was observed in 4 patients. Assessment of treatment response rate (secondary endpoint) is ongoing and will be reported at the meeting.Conclusions: Overall safety profile of the study treatment was consistent with pivotal trial of Pralatrexate in R/R PTCL. Leucovorin as adjunctive treatment resulted in a significant reduction in rates of both ≥Grade 2, and ≥Grade 3 mucositis and should be considered in patients treated with Pralatrexate. DisclosuresShustov:SPECTRUM PHARMACEUTICALS: Consultancy, Research Funding. Bhat:SPECTRUM PHARMACEUTICALS: Employment.

Implementation of a Clinical Pathway for Chest Pain in a Pediatric Emergency Department.

To evaluate the impact of a pediatric emergency department (ED) chest pain clinical pathway on resource utilization. Motivated by perceived overuse of cardiology consultation for non-cardiac chest pain in the ED, clinicians from the Divisions of Cardiology and Emergency Medicine collaboratively developed a chest pain clinical pathway, educated staff, and implemented the pathway on March 1, 2014. We reviewed records of children aged 3 to 18 years without prior diagnoses of heart disease who presented to the ED with chest pain between March 1, 2013, and April 22, 2015. We compared diagnostic testing rates, ED length of stay, and cardiology consults before and after implementation of the pathway. A total of 1687 patients were pathway eligible (675 patients preimplementation and 1012 postimplementation). Resource utilization was lower than expected before pathway implementation and remained low after implementation. There was a statistically significant reduction in rates of chest x-ray ordering after pathway implementation and ED length of stay but no change in other diagnostic testing or cardiology consultation. Follow-up in our health care system for pediatric chest pain increased from 15% to 29% with implementation, but none of these visits resulted in the diagnosis of a new cardiac condition. There were no instances identified where use of the pathway resulted in missed cardiac disease. Implementation of a clinical pathway for pediatric chest pain did lead to a reduction in chest x-ray ordering in the ED and was associated with a higher rate of outpatient follow up for non-pathologic chest pain. Preimplementation utilization was lower than the prepathway perceptions of overuse suggested.

High-Temperature Water-Based Mud Faces Challenges Offshore Sarawak, Malaysia

This article, written by Special Publications Editor Adam Wilson, contains highlights of paper OTC 28484, “Learnings From the High-Temperature Water-Based-Mud Application in Offshore Sarawak,” by M. Abshar M. Nor, SPE, M. Solehuddin A. Razak, and Lingges Devadass, Petronas, prepared for the 2018 Offshore Technology Conference Asia, Kuala Lumpur, 20–23 March. The paper has not been peer reviewed. Copyright 2018 Offshore Technology Conference. Reproduced by permission. The reservoir section of a gas field offshore Sarawak, Malaysia, consists of two massive pinnacle carbonate structures with heterogeneous porosity and permeability and many vugs and faults. Severe to total loss of circulation was expected along with a high bottomhole temperature (BHT). Considering the high risk of lost circulation, the drilling-fluid strategy involved designing and testing a high-temperature (HT) -tolerant water-based mud (WBM). While the main hole was drilled successfully with the HT WBM, the sidetrack experienced a significant reduction in rate of penetration (ROP). Well Design and Execution Challenges During the design stage, determination of the severity of losses in the carbonate formation was met with high uncertainty. Consequently, a WBM system was selected to drill the 8½-in. reservoir section. A shale formation was predicted to be above the carbonate section, and a 95/8-in. casing was planned to be set as close as possible at the top of the carbonate to isolate the shale. With the 95/8-in. casing in place, the WBM was to be used to drill the shoe track and the remaining small shale section before entering the carbonate reservoir. The BHT of the reservoir was predicted to be 370°F, which was extrapolated from data from offset wells. In addition, the pore pressure in the reservoir was overpressured approximately 14 lbm/gal because of a gas column in the carbonate. The high BHT coupled with the high mud-weight requirement of up to 14.5 lbm/gal led to the design of an unconventional HT WBM, which was a first for the operator. Special attention also was given to the corrosion risk on the drillstring from expected hydrogen sulfide levels up to 150 ppm and carbon dioxide levels up to 20% in the reservoir. Predrill Laboratory Study Laboratory tests were conducted to address major well challenges and overall performance of the system under extreme borehole temperatures. To ensure the mud system was able to withstand temperatures up to 400°F, a synthetic polymer was introduced to the mud design. Several mud formulations were tested and fine-tuned to achieve well-specific mud specifications for optimal hydraulic capability. Laboratory tests in accordance with American Petroleum Institute Recommended Practice 13B were conducted to evaluate the mud properties with various concentrations of additives. Four samples—Samples A, B, C, and D—were prepared and submitted to the same test procedure to understand the mud rheological behavior upon exposure to the HT environment.

265. Clinical utility of sFlt1/PlGF in the management of hypertensive pregnancies in India

Angiogenic biomarkers have been shown to predict adverse maternal/perinatal outcomes. This study explored the outcomes of hypertensive pregnancies using sFlt1/PlGF ratio in the third trimester. A single site prospective cohort study was done at a tertiary center in India. Singleton pregnancies with chronic/gestational HTN between 28 and 37 weeks were enrolled. sFlt1/PlGF was measured in serum samples on Roche platform. The results were stratified as Screen negative, Borderline positive or Screen positive (Table 1). All patients were delivered based on clinical parameters. Data on 31 pregnancies (resulting in 85 samples) was analyzed using sFlt1/PlGF ratio (cases) and compared with 93 contemporaneous pregnancies who were monitored without the biomarkers (controls).With the biomarkers, there was an increase in diagnosis of preeclampsia and IUGR along with higher rates of preterm delivery less than 30 weeks with an increase in the NICU stay. However, there was a significant reduction in rates of adverse maternal outcomes. 9 cases with maternal (peripartum) complications in controls included 2 cases of abruption, 6 cases of HELLP/partial HELLP and 1 case of pulmonary edema as compared to only 1 case of pulmonary edema among cases. No cases of IUFD was reported with biomarkers (Table 2). Serial testing with sFlt1/PlGF in the third trimester could help avert serious adverse maternal and perinatal outcomes in hypertensive pregnancies. Larger prospective studies are needed.