Suboptimal Rates Research Articles

Utilization of Immunization Information Systems (IIS) among independently owned community pharmacies: A national survey

Background/ObjectiveImmunization information systems (IIS) consolidate provider-submitted immunization information. We reassessed independently owned community pharmacies’ IIS enrollment, verification of immunizations needs via IIS records retrieval, and immunization records reporting to IISs following post-pandemic shifts in community pharmacy operations. MethodsA cross-sectional online survey of National Community Pharmacists Association pharmacist, pharmacy owner, and pharmacy technician members was conducted in Fall 2022. Results202 complete responses were analyzed. Margin of error was an estimated 7 %. Respondents were: 53.2 % female, ∼87 % White, 69.8 % managers, and 86.1 % practicing in standalone community pharmacies. Almost all (91.6 %) were enrolled in IIS. About two-thirds frequently or always utilized IIS to retrieve immunization records prior to immunization. On average, 81.2 % of influenza and 83.5 % of non-COVID/non-influenza vaccination records were submitted. ConclusionsEnrollment rates are high among studied pharmacies, as are records reporting rates. However, records retrieval rates are suboptimal. Future work should focus on addressing suboptimal retrieval rates within immunization-providing pharmacies.

How to increase COVID-19 vaccination among a population with persistently suboptimal vaccine uptake? Evidence from the North Macedonia mobile vaccination and public health advice caravan

Over three years since the first COVID-19 vaccine was approved, many countries still have suboptimal vaccination rates despite holding great amounts of vaccines. Overall, there is little evidence on which policies are more effective to encourage vaccination, particularly in countries where a large share of the population remains unvaccinated. In this study, we examine the effectiveness of a community-based intervention carried out in March 2022 in North Macedonia, a country with a large and persistent share of the population that remains unvaccinated. The intervention, spearheaded by the Ministry of Health and supported by the World Health Organization and UNICEF, consisted of a mobile caravan offering vaccination and public health advice to different locations across the country on different days. Results from our staggered difference-in-difference model show that the mobile vaccination caravan increased daily vaccination rates by 7.7 vaccines per 100,000 inhabitants during the three weeks after the day of the caravan visit. This corresponds to a 35 % increase with respect to pre-intervention vaccination rates. We estimate a cost-effectiveness of 25.4 US dollars (USD) per additional vaccination induced. These results point to mobile caravan vaccines as an effective and cost-effective strategy to increase COVID-19 vaccination rates, even in a context of persistently suboptimal uptake.

High-dimensional IV cointegration estimation and inference

A semiparametric triangular systems approach shows how multicointegrating linkages occur naturally in an I(1) cointegrated regression model when the long run error variance matrix in the system is singular. Under such singularity, cointegrated I(1) systems embody a multicointegrated structure that makes them useful in many empirical settings. Earlier work shows that such systems may be analyzed and estimated without appealing to the associated I(2) system but with suboptimal convergence rates and potential asymptotic bias. The present paper develops a robust approach to estimation and inference of such systems using high dimensional IV methods that have appealing asymptotic properties like those known to apply in the optimal estimation of cointegrated systems (Phillips, 1991). The approach uses an extended version of high-dimensional trend IV (Phillips, 2006, 2014) estimation with deterministic orthonormal instruments. The methods and derivations involve new results on high-dimensional IV techniques and matrix normalization in the limit theory that are of independent interest. Wald tests of general linear restrictions are constructed using a fixed-b long run variance estimator that leads to robust pivotal HAR inference in both cointegrated and multicointegrated cases. Simulations show good properties of the estimation and inferential procedures in finite samples. An empirical illustration to housing stocks, starts and completions is provided.

Metabolites of Trichoderma harzianum re-balance T-reg/Th-17 cytokine axis in epileptic rats

BackgroundRecurrent seizure is synchronous neuronal network hyperexcitation. Even though many anti-epileptic drugs (AEDs) are available, but have several drawbacks, including multiple drug interactions, suboptimal response rates, significant adverse effects, and a narrow therapeutic index. Trichoderma is a biocontrol agent which maintains stress-related gene expression to adapt to unstable environmental conditions. The current study sought to delineate the ameliorative effects of metabolites of Trichoderma harzianum (T. harzianum) culture filtrate (ThCF) by assessing the functions of T regulatory cells and rebalancing oxidative stress.MethodsExperimental rats were divided into control, epileptic, valproic acid-treated, and T. harzianum cultured filtrate (ThCF). Lipid peroxidation, nitric oxide, and antioxidant defense enzymes were estimated. Moreover, interleukins-6, -10, -17, tumor necrosis factor (TNF-α), and transforming growth factor (TGF-β) were estimated using ELISA kits, in addition to T-reg markers; cytotoxic T-lymphocyte-associated protein 4 (CTLA4), and forkhead box P3 (FOXP3) were estimated by qRT-PCR.ResultsData revealed that the T. harzianum cultured filtrate (ThCF) retarded the lipid oxidation rate and has antioxidant activities, as well as increased levels of GPx, CAT, and SOD. Moreover, ThCF re-balances T-reg/Th-17 cytokines, restoring the pro/anti-inflammatory cytokines and Treg markers, e.g., FOXP3 and CTLA-4, to their normal level.ConclusionTrichoderma harzianum has a potent antioxidant activity with high capacity to scavenge ROS and downregulate all T-reg markers. Therefore, the present data are directed toward the characterization of new active constituents of secondary metabolites of T. harzianum with significant therapeutic functions in several diseases. The promising findings may suggest more clinical and experimental scenarios to reduce AED’s drawbacks and side effects.

Update on HPV Vaccination Policies and Practices in 17 Eastern European and Central Asian Countries and Territories.

In 2021, a survey was conducted as part of the regional program of the United Nations Population Fund (UNFPA) Regional Office for Eastern Europe and Central Asia (EECA) to assess the policies and practices relating to HPV vaccination and cervical cancer screening in the 17 countries and territories included in this region. Since then, very substantial progress has been made with HPV vaccination across the region so another survey was conducted establish the current situation. A 10 question survey covering the policies, plans and practices for HPV vaccination was prepared. As cervical cancer prevention is a priority for the UNFPA, its offices in the 17 countries and territories included in this study are well placed to identify the people who can provide authoritative data for this survey. Working with the UNFPA offices, the questionnaires were sent to these national experts in May 2023, with data collected until 30 June 2023. All countries and territories returned completed questionnaires. In the period from 30 June 2021 to 30 June 2023, the number of countries and territories that have implemented or are implementing HPV vaccination programs has doubled. As of 30 June 2021, only 6 of 17 countries and territories had implemented national HPV vaccination programmes, and by 30 June 2023, another 6 could be added to this list. Of the 4 countries with sub-optimal vaccination coverage rates in 2021, none showed substantial improvement over the 2-year period. The implementation of HPV vaccination programs across the region is progressing very rapidly with ≈70% of the countries and territories implementing or having implemented national programs. However, greater attention needs to be given to ensuring that both the old and the new programs will achieve high coverage rates.

COVID mRNA Vaccination Responses in Individuals with Sickle Cell Disease: An ASH Research Collaborative Clinical Trial Network Study

A multi-state, long term follow-up study of individuals with sickle cell disease (SCD) demonstrated an increase in mortality and morbidity in children and adults with COVID. mRNA vaccines are recommended for all SCD patients. Vaccination in individuals with SCD for other infections may be associated with impaired antibody responses. Concern has also been raised about whether mRNA vaccines, through a unique mechanism, may induce disease-related-complications in patients with SCD resulting in a suboptimal immunization rate. The ASH Research Collaborative Clinical Trial Network (ASH RC CTN) performed a mRNA vaccine trial to assess whether antibody responses following COVID vaccination were adequate to induce immunity and whether mRNA vaccination precipitated any toxicity unique to SCD patients. We prospectively studied patients at 8 of the ASH RC CTN sites: Johns Hopkins, Prisma, Duke, UT Southwestern, Medical College of Wisconsin, UCSF, Children's National, and Montefiore. Eligible patients with SCD had not yet received the COVID vaccine. We enrolled 59 patients and 47 received at least one vaccination. All vaccinated patients received the monovalent Pfizer vaccine. Forty-two patients received two vaccinations and provided baseline blood samples prior to vaccination and 2 months after the initial vaccination. For this report, data for 41 paired samples were available for analysis of IgG reactivity against the receptor binding domain (RBD) of the SARS-CoV-2 spike protein. Samples were taken from 7 patients (17%) under 3 years of age, 17 (41%) from older children (3-17 years of age), and 17 (41%) from adults (18-53 years of age). The majority of patients had HbSS (73%) or HbSC (22%), and one of each had either HbS beta 0 (2%) or HbS beta+ (2%). Concurrent therapies included hydroxyurea (59%), voxelotor (17%), crizulizumab (2%), intravenous immunoglobulin (2%), and chronic transfusions (2%). Five had a history of splenectomy (12%). Seventy-five percent of patients received their initial vaccination within 10 days of the baseline visit, and the median time between initial vaccination and post vaccination blood draw was 62 days. One patient experienced a COVID infection 5 days after the baseline visit, but prior to vaccination. This individual later received two vaccinations and submitted blood samples for analysis. Post-vaccination fever/chills, arthralgias, emesis, or local vaccination pain/erythema were reported in 49% of the patients. None reported fever that required inpatient admission. Seven patients (17%) reported a total of 8 episodes of vaso-occlusive pain within 14 days of the 1st vaccination. Of these, three required evaluation and treatment at a medical facility, and one patient was admitted for inpatient care. Antibody responses are shown in the Figure. Fourteen patients (34%) were seronegative at baseline, all with IgG ≤ 0.48 arbitrary units (AU). Twenty-seven patients (66%) were seropositive at baseline with a median IgG = 4.59 AU. Post-vaccination demonstrated a median IgG = 32.2 AU for the initially seronegative patients, and IgG = 102 AU for those initially seropositive. All initially seronegative patients converted to seropositive post vaccination; although post-vaccination IgG levels were lower than in the patients who were initially seropositive (Wilcoxon rank sum test, p-value = 0.0062). Overall, patients with sickle cell disease had side effects similar to those in the general population, and patients with SCD also responded to the COVID mRNA vaccination as expected after 2 months. The 6-month titers will be analyzed in the early fall. To our knowledge, this is the largest mRNA vaccine efficacy and safety trial in individuals with SCD, and it also marks the first evaluation of vaccine safety and antibody response in very young children with SCD.

Real-World Response Rates across Lines of Therapy Among Patients with Relapsed/Refractory Follicular Lymphoma

Background: Follicular lymphoma (FL) is the most common indolent subtype of non-Hodgkin lymphoma. Despite the generally indolent nature of the condition, there are subgroups of FL patients who may not have an indolent experience, with their disease not responding to multiple lines of therapy. Thus, optimization of novel therapy could improve patient outcomes. This analysis examined treatment patterns, overall response rates (ORR), and complete response (CR) rates by line of therapy (LOT) in relapsed/refractory (R/R) FL in third-line or later (3L+) therapy. Methods: This retrospective observational study was conducted using the COTA database, comprising electronic health records (EHR) from academic (50%) and community (50%) practices in the US. Adults with a confirmed diagnosis of FL, with 3L+ therapy initiation in 2010 or later, at least 3 months of follow-up, and any response assessment after 3L initiation were included. LOTs eligible for inclusion met the following conditions: treatment with an anti-CD20, alkylating agent, or lenalidomide, and no investigational drug in the selected LOT. In addition, patients with only 3L had that line selected; patients with more than 1 eligible LOT had only 1 LOT randomly selected for the analysis. Outcomes were assessed by FL International Prognostic Index (FLIPI), double refractory (DR) status, and type of therapy. DR status was defined as being refractory (disease progression or initiation of a new LOT in <6 months) to an anti-CD20 monoclonal antibody therapy and an alkylating agent. Chemoimmunotherapy (CIT) regimens included obinutuzumab/rituximab + bendamustine (OB/BR), rituximab/obinutuzumab+cyclophosphamide, doxorubicin, vincristine, and prednisolone (R/O+CHOP), R/O+CVP, R/O+other alkylating agent, and R/O+fludarabine and cyclophosphamide (FC). Novel therapies included lenalidomide + rituximab (R 2), phosphatidylinositol-3-kinase (PI3K) inhibitors, and chimeric antigen receptor T-cell therapy (CAR T). The proportion of patients with CR (as retrieved from clinician documentation in EHR) as the physician-reported response within each LOT was calculated. ORR was calculated as the proportion of patients with a CR or PR. Response rates were reported by LOT (3L, 4L, 5L+) and stratified by patient age (<65 vs ≥65 years), FLIPI score (low/intermediate vs high), and DR (not DR vs DR). Results: Overall, 240 patients with R/R 3L+ FL were included: 3L (n=140), 4L (n=55), and 5L+ (n=45). At 3L initiation, median age was 66 years and most patients were male (58.8%), White (89.6%), and had FL grade 1/2 (72.5%); 47.9% of patients were DR, 22.9% had novel therapy use, and 51.3% had CIT use. A total of 152 patients had FLIPI scores available, 38.2% of whom had high-risk scores at 3L initiation. Among all R/R 3L+ FL patients, ORR was 67.9%, with CR in 30.4% ( Figure 1). Response rates decreased across LOTs for both ORR (3L: 72.9%; 4L: 65.5%; 5L+: 55.6%) and CR (3L: 35.0%; 4L: 30.9%; 5L+: 15.6%) ( Figure 2). ORR was higher among all R/R 3L+ FL patients <65 years vs ≥65 years (75.5% vs 62.3%), as was CR rate (36.3% vs 26.1%). Among the subset of R/R 3L+ FL patients with a FLIPI score, those with low/intermediate risk vs high risk had a greater ORR (78.7% vs 58.6%) and CR rate (36.2% vs 20.7%). ORR was also higher for R/R 3L+ patients without DR status vs with DR status (73.0% vs 63.2%), as was CR rate (37.4% vs 24.0%). Patients receiving novel therapy 3L+ had an ORR of 70.9% and a CR rate of 27.3%. Among R/R 3L+ FL patients, more LOTs of CIT were associated with decreased response rates; patients with CIT in 1 LOT vs CIT in >2 LOTs had greater ORR (76.4% vs 69.2%) and CR rate (37.4% vs 26.9%). Conclusions: This analysis provides granular details on patients with R/R FL with poor prognosis. Patients with FL who progress to later LOTs have worsening response rates. This analysis included more patients with later LOTs than previously published reports, providing additional insight into response rates as treatment progresses. Lower response rates were observed among patients ≥65 years, those with a high-risk FLIPI score, and those with DR status. The high utilization of CIT in later LOTs, despite suboptimal response rates, especially among subgroups of patients with FL who may not have indolent experience of the disease, underlines the need for efficacious alternative therapies in patients with R/R 3L+ FL.

The politics of vaccination: a closer look at the beliefs, social norms, and prevention behaviors related to COVID-19 vaccine uptake within two US political parties

ABSTRACT COVID-19 vaccine hesitancy and suboptimal vaccine uptake rates are pressing public health challenges. Vaccine hesitancy has been observed for different vaccines. For COVID-19 vaccines, multiple factors influence vaccine uptake in the U.S. including political ideology. A more nuanced understanding of the factors influencing COVID-19 vaccine uptake within political parties is needed. This study assesses the relationship between known vaccine hesitancy factors and vaccine uptake within two major political parties. Data from 804 U.S. participants in an online survey from June 2021 was used to assess the association between COVID-19 vaccine uptake (no dose vs. any dose) and categories of factors thought to influence vaccine uptake (sociodemographic variables, COVID-19 disease and vaccine belief variables, belief in COVID-19 prevention behavior variables, and social network features variables) for Republicans and Democrats using bivariate and multivariate regression. 65.4% of the sample reported having received at least one dose of the COVID-19 vaccine (22.6% Republican and 52.1% Democrat). In the total sample bivariate model, Democrat participants had significantly greater odds of having received a dose of the vaccine as compared to Republican participants (OR = 2.51, 95%CI = 1.73–3.64). In adjusted models, the speed of vaccine development was negatively associated with vaccine uptake for both Republicans (aOR = 0.18, 95%CI = 0.06–0.57) and Democrats (aOR = 0.40, 95%CI = 0.19–0.86), as was concern about side effects from the vaccine (Republicans: aOR = 0.15; 95%CI = 0.05–0.47; Democrats: aOR = 0.14, 95%CI = 0.06–0.31). COVID-19 vaccine uptake among Republicans, but not Democrats, was associated with belief that the vaccine prevents COVID-19 (aOR = 3.29, 95%CI = 1.29–8.37) and belief about friends’ vaccine intentions (aOR = 6.19, 95%CI = 2.39–16.05). There were no significant factors unique to Democrats. Concerns about aspects of COVID-19 vaccine safety for both political groups suggest that vaccine advocacy interventions should universally address these factors. However, Republican beliefs in vaccine efficacy and in friends’ vaccine intentions suggest a need for Republican-specific messaging.

A booster dose of SARS-COV-2 vaccine improves suboptimal seroconversion rates in patients with inflammatory bowel disease. Results of a prospective multicenter study of GETECCU (VACOVEII study)

BackgroundThe response to SARS-CoV-2 vaccination decreases in inflammatory bowel disease (IBD) patients, specially under anti-TNF treatment. However, data on medium-term effectiveness are limited, specially using new recommended seroconversion rate (>260BAU/mL). Our aim was to evaluate the 6-month>260 BAU-seroconversion rate after full vaccination and after booster-dose. MethodsVACOVEII is a Spanish multicenter, prospective study promoted by GETECCU. IBD patients full vaccinated against SARS-CoV-2 and without previous COVID-19 infection, treated or not with immunosuppressants, were included. The booster dose was administered 6 months after the full vaccination. Seroconversion was set at 260BAU/mL, according to most recent recommendations and was assessed 6 months after the full vaccination and 6 months after booster-dose. ResultsBetween October 2021 and March 2022, 313 patients were included (124 no treatment or mesalazine; 55 immunomodulators; 87 anti-TNF; 19 anti-integrin; and 28 ustekinumab). Most patients received mRNA-vaccines (86%). Six months after full vaccination, overall seroconversion rate was 44.1%, being significantly lower among patients on anti-TNF (19.5%, p<0.001) and ustekinumab (35.7%, p=0.031). The seroconversion rate after booster was 92%. Again, anti-TNF patients had a significantly lower seroconversion rate (67%, p<0.001). mRNA-vaccine improved seroconversion rate (OR 11.720 [95% CI 2.26–60.512]). ConclusionThe full vaccination regimen achieves suboptimal response in IBD patients, specially among those anti-TNF or ustekinumab. The booster dose improves seroconversion rate in all patients, although it remains limited in those treated with anti-TNF. These results reinforce the need to prioritize future booster doses in patients on immunosuppressants therapy, specially under anti-TNF, and using mRNA-vaccines.

Exploring Delivery of Adolescent Preventive Health Services During the COVID-19 Pandemic: Perceptions and Experiences Shared by Healthcare Professionals

Abstract Background While unmitigated vaccine hesitancy was already growing before the emergence of COVID-19, the global pandemic has introduced additional challenges to the immunization sector. Despite the benefits, routine preventive care was forestalled by challenges related to pandemic lockdowns/quarantine, parental reluctance to seek preventative services, poor access to healthcare, loss of income and/or health insurance, and the inability of children under 12 to be immunized against the coronavirus. Considering the potential impacts caused by the pandemic’s disruption of adolescent preventative care services, we explored the experiences of adolescent healthcare providers in Tennessee and Georgia in providing care throughout the COVID-19 pandemic. Methods A series of in-depth qualitative interviews were conducted between December 2020 and May 2021 via the video conferencing platform, Zoom, among a diverse group of adolescent healthcare providers (n=16) representing 5 healthcare practices located within the southeastern states of Georgia and Tennessee. Audio recordings were transcribed verbatim and analyzed using a rapid qualitative analysis framework, guided by the grounded theory and inductive approach. Results Preventive adolescent services were adversely impacted by the COVID-19 pandemic at all participating practices. Participants highlighted an initial decrease in patients due to the pandemic, despite the implementation of protective measures such as an increase in sanitation measures, hand washing, separation of sick and wellness visits, mask mandates, and telehealth/video conferencing opportunities. While practices continued to distribute educational materials, many removed material from their waiting rooms due to sanitary concerns related to COVID-19. Participants reported that patient-provider communications; effective use of presumptive languaging; periodic reminders/recall messages; provider’s personal recommendation on vaccine safety/efficacy; early initiation of human papillomavirus (HPV) vaccination series at 9 years; community partnerships with health navigators/vaccine champions/vaccine advocates; use of standardized forms/prewritten scripts/standard operating protocols for patient-provider interactions; and vaccine promotion through social media, brochures/posters/pamphlets, as well as outreach to schools and churches, served as facilitators to adolescent HPV vaccine uptake. Conclusions By exploring the perceptions and experiences of adolescent healthcare providers, our research identified key factors influencing adolescent vaccination uptake and its relatedness to the COVID-19 pandemic. We argue our findings support and encourage the development of personalized patient-provider communications, trusting relationships, effective use of presumptive languaging, and counteraction of misinformation as solutions to suboptimal preventative services and vaccination coverage rates. Implementation of these comprehensive strategies could not only ameliorate routine adolescent vaccination uptake but could also aid in the expansion of COVID-19 vaccine acceptance on a sizable scale.

Achieving high selectivity in photoelectrochemical oxidation of glycerol on WO3 nanosheets coupled with TiO2 nanorods arrays

Developing highly efficient photocatalysts for the selective conversion of glycerol into valuable chemicals is of paramount importance. However, achieving the selective oxidation of glycerol to valuable C3 chemicals poses significant challenges. In this study, we employed a two-step hydrothermal method to synthesize a photoelectrochemical (PEC) photocatalyst composed of WO3 nanosheets assembled on TiO2 nanorod arrays. The synergistic interaction between WO3 and TiO2 led to outstanding performance in the selective conversion of glycerol (GLY) into glyceraldehyde (GLD) and 1,3-dihydroxyacetone (DHA). The photocatalyst achieved a selectivity of 61% for GLD and 92% for GLD + DHA, with formation rates of 319 and 160 mmol m-2h−1, respectively. Despite the excellent charge transfer properties of TiO2 nanorods, they displayed suboptimal glycerol conversion rates and tended to oxidize glycerol into lower-value products. The introduction of WO3 nanosheets in the Z-scheme heterojunction improved charge separation, enhanced glycerol adsorption and facilitated the desorption of GLD and DHA, thus improving the selectivity of GLD + DHA. This study unveils a promising approach to efficiently oxidize glycerol and demonstrates the crucial role of catalyst design in achieving selective and high-yield chemical transformations.

AHP P04 Utilisation of Jejunostomy (JEJ) placement post Oesophagogastrectomy (OG) surgery and the difference in unintentional weight loss between patients who were placed with a JEJ at the time of surgery compared to those without

Abstract Background The optimal pathway for reinstating nutrition orally or enterally remains a matter of debate post OG surgery. Historically all patients undergoing OG had routine JEJ placement and there are many studies to support this. However more recently, some trusts are moving away from this notion and opting for selective JEJ placement due to suboptimal tube utilisation rates, psychological impact for patients, enhanced recovery after surgery (ERAS) pathways, wider range of oral nutritional supplements on the market, adaptive hospital menus and snack boxes, Naso-jejunal tubes (NJT) being placed instead of JEJ, JEJ tube complications and more enhanced specialist Dietetic input. Methods Data was collected retrospectively from electronic notes for all patients who underwent an OG between April 2020- April 2021 which was during the start of the covid pandemic. The data was reviewed for 2 years following their surgery and compared percentage weight loss of patients with JEJ placed versus patients without at 1-2 months, 3 months, 6 months, 9 months, 1 year and 2 years post surgery. Utilisation rates of JEJ tube were also reviewed alongside establishing if patients did not have JEJ placement at time of OG, required enteral feeding as part of their recovery. Results 58 OG’s Conducted between 30/4/2020-29/4/21, of which 65.5% had JEJ placed. Conclusions Selective JEJ placement during OG surgery requires careful consideration given 23.7% patients didn't use JEJ post discharge and 2years post OG, weight loss was the same in both groups. However, 1year post OG, the non-JEJ group lost nearly double the amount to the JEJ group, highlighting further research is required to inform this debate; especially as the weight loss could be attributed to cancer recurrence which has not been accounted for. Collaborative working between Dietitians, surgeons and nurse specialists is essential if selective JEJ placement is to occur. Data will be repeated during non-covid times to yield more meaningful data.

The benefit of a double ventricular extra stimuli protocol to improve functional substrate mapping during ablation of ventricular tachycardia. - The S3-VT-FREE project

Abstract Introduction Ablation of ventricular tachycardia (VT) based on substrate-based mapping has been proposed to itemize areas of interest identifying areas of low-voltage, late potentials (LPs), and deceleration zones (DZs). However, partial delineation of targets for ablation is likely responsible for a suboptimal long-term success rate. The abnormal electrograms (EGMs), featuring low-voltage near-field components may be hidden within the high-amplitude far-field signal. We hypothesized that the acquisition of functional mapping after double ventricular extrastimuli (S3 protocol) would uncover relevant areas of functional substrate that could be missed during sinus or S1 map. We aim to evaluate the potential benefit and the feasibility of functional substrate mapping using an S3 protocol for VT ablation and to assess its colocalization with detected corridors using late gadolinium enhancement magnetic resonance imaging (LGE-MRI). Methods We included consecutively 29 patients with structural cardiomypathy who underwent a VT ablation. The S3 protocol included: (1) assessment of the ventricular effective refractory period (ERP), (2) pacing protocol from the apex of the right ventricle with S1 x 6 (cycle length: 600ms) followed by S2 (ERP+30ms) and S3 (ERP+50ms). Electroanatomical mapping was acquired with the EnsiteX system (Abbott, IL) using HD Grid catheter and omnipolar signals. ILAMs were used to identify deceleration zones and areas of late potentials were identified for all maps. A non-invasive substrate assessment was done with LGE-MRI and post-processing with a commercially available system (ADAS3D, Spain) with automated identification of corridors. Results The S3 protocol was completed in 25 of the 29 procedures (86.2%). The repeated induction of ventricular arrhythmias did not allow for full protocol of the S3 protocol in 4 patients (13.8%). The functional substrate identified during the S3 activation mapping was significantly more extensive than the one identified using S1 and S2 activation mappings (p&amp;lt;0.05) (Table). The S3 protocol unmasked a higher number of DZs (p&amp;lt;0.01), a wider area of LPs (p&amp;lt;0.01), and a longer duration of the DZs (p=0.01). All DZ maps were compared with preprocedural cardiac magnetic resonance. The number of DZs matching with conduction corridors identified by LGE-MRI was higher in the activation mapping of S3 compared with the S1 and S2 ones (p=0.02). After VT ablation based on an S3 protocol, 88% of patients have been VT free during a median follow-up of 9 months. Conclusions This novel substrate-based protocol to assess the ventricular functional substrate is feasible in the majority of patients (86.2%) and allows for a better identification of targets for ablation and could facilitate VT ablation, and improve the prognosis of the patients after ablation.

Addressing Attrition from Psychotherapy for PTSD in the U.S. Department of Veterans Affairs

The United States Department of Veterans Affairs (VA) uses a systematized approach for disseminating evidence-based, trauma-focused psychotherapies for post-traumatic stress disorder (PTSD). Within this approach, veterans with PTSD must often choose between Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), each delivered in their standard protocols. Many veterans have been greatly helped by this approach. Yet limiting trauma-focused therapy to these two options leaves the VA unable to fully address the needs of a variety of veterans. This limitation, among other factors, contributes to the suboptimal attrition rates within the VA. The present review proposes solutions to address treatment barriers that are both practical (such as time and travel constraints) and psychological (such as resistance to trauma exposure). By reducing barriers, attrition may lessen. Proposed countermeasures against practical barriers include intensive protocols, shortened sessions, telehealth, smartphone application delivery, or any combination of these methods. Countermeasures against psychological barriers include alternative evidence-based treatment programs (such as Acceptance and Commitment Therapy), intensive protocols for exposure-based treatments, and the integration of components from complementary treatments to facilitate PE and CPT (such as Motivational Interviewing or family therapy). By further tailoring treatment to veterans’ diverse needs, these additions may reduce attrition in VA services for PTSD.

Abstract 15611: Disparities in Hypertension Control Amidst the Pandemic: A Multi-Year Analysis Using Multiple Hospital Database

Introduction: Hypertension, a pervasive global health concern, affects roughly half of US adults and can lead to serious health issues if uncontrolled. This study utilized the Epic Cosmos anonymized database to evaluate blood pressure (BP) control efficacy and related disparities among hypertensive patients from 196 healthcare institutions. Additionally, we explored the pandemic impact on these outcomes. Hypothesis: To evaluate blood pressure (BP) control efficacy and related disparities among hypertensive patients from 196 healthcare institutions using the Epic Cosmos anonymized database. Methods: Using the Epic Cosmos database, hypertension control rates from 2018 to 2022 were evaluated and stratified by patients' socio-demographic profiles. A multivariable logistic regression analysis identified factors associated with BP control rates. Results: In 2022, the study included 13.4 million hypertensive patients aged 18 and older. Of these, 66.0% achieved BP control (BP&lt; 140/90 mm Hg), 31.0% reached stricter control (BP&lt;130/80 mm Hg), and 7.0% had severely uncontrolled hypertension. Control rates were lower among Non-Hispanic Blacks (59.4%) compared to Non-Hispanic Whites (67.5%) with an adjusted odds ratio (AOR) of 0.749 (95% confidence interval (CI): 0.746-0.752). Self-pay patients were less likely to achieve control than insured patients (58.8% vs 66.8%, AOR: 0.79, 95% CI: 0.78-0.80). BP control rates fluctuated from 2018 to 2022, reflecting the pandemic's impact. Conclusions: The findings highlight suboptimal hypertension control rates and disparities in the US, emphasizing the need for tailored hypertension management initiatives. These should consider identified disparities and ensure accessibility and cultural sensitivity, aligning with the American Heart Association guidelines.

Abstract 16145: Statin Prescription and Cholesterol Control Among Persons With HIV Without Existing Atherosclerotic Cardiovascular Disease

Introduction: Persons with HIV (PWH) have significantly increased risk for atherosclerotic cardiovascular disease (ASCVD) including acute MI. The REPRIEVE trial recently demonstrated that statins reduce cardiac events in PWH at low-intermediate ASCVD risk. However, statins are underutilized even among PWH who are at high ASCVD risk. Accordingly, we sought to characterize current gaps in cholesterol management in a population of PWH and identify factors associated with statin prescription. Methods: We conducted a retrospective study of PWH 40 years and older without existing ASCVD at three HIV clinics in San Francisco, U.S. from 2019-2022. We used ICD-10 codes and electronic health record data to assess cholesterol screening and treatment. Multivariable logistic regression models evaluated clinical factors associated with statin prescription among those eligible. Results: The clinical cohort included 2,567 PWH, of which 14% were female, 54% White, 24% Hispanic, and 18% Black, with a median age of 55 years. Among those with complete data on the components of the ASCVD Risk Estimator, the median 10-year ASCVD risk was 7.6%. The majority of PWH (87%) had undergone cholesterol screening, and 43% were eligible for statin therapy based on current guidelines (Figure 1). Of the 1,097 PWH eligible for statins, only 478 (44%) were prescribed statins. Among statin-eligible PWH, statin prescription was positively associated with older age, antiretroviral therapy, undetectable viral load, and chronic kidney disease and negatively associated with hepatitis C. Cholesterol control (non-HDL cholesterol &lt;130 mg/dL) was achieved in 47% of the study population. Conclusions: PWH in this study demonstrate suboptimal rates of statin prescription and cholesterol control. Identification of PWH eligible for statin therapy, prescribing statins, and ensuring lipid control are opportunities for improving primary prevention of ASCVD among PWH at heightened risk.

Metronidazole prescribing practices in Australian hospitals: Measuring guideline compliance and appropriateness to support antimicrobial stewardship

BackgroundMetronidazole is a commonly prescribed antimicrobial in Australian hospitals. Inappropriate use may increase risks to patient care, such as toxicities and antimicrobial resistance. To date, there is limited information on the quality of metronidazole prescriptions to inform antimicrobial stewardship and quality improvement initiatives. This study aims to describe the quality of metronidazole prescribing practices in Australian hospitals. MethodsRetrospective data analysis of the Hospital National Antimicrobial Prescribing Survey (Hospital NAPS). Data were collected by auditors at each participating hospital using a standardised auditing tool. All data from 2013 to 2021 were de-identified and analysed descriptively. Variables included were antimicrobial prescribed, indication, guideline compliance and appropriateness. ResultsMetronidazole was the fifth most prescribed antimicrobial in the Hospital NAPS dataset (2013–2021), accounting for 5.7 % (n = 14,197) of all antimicrobial prescriptions (n = 250,863). The proportion of metronidazole prescriptions declined by 2 % from 2013 to 2021 (p < 0.001). The most common indications were surgical prophylaxis (15.3 %), diverticulitis (9.4 %), aspiration pneumonia (7.3 %). Over half (53.5 %) of metronidazole prescriptions were deemed compliant with prescribing guidelines and 67.8 % were deemed appropriate. These rates were comparatively lower than the overall results of all antimicrobials. The primary documented reason for inappropriateness was that the spectrum was too broad (34.2 %). Surgical prophylaxis had the lowest rates of guideline compliance (53.8 %) and appropriateness (54.3 %). ConclusionsMetronidazole remains widely used in Australian hospitals with suboptimal rates of guideline compliance and appropriateness. A noted area for improvement that we identified was using metronidazole when its spectrum was too broad, possibly when anaerobic therapy is unnecessary. With increasing international adoption of the Hospital NAPS programme, future comparative studies will be critical to identify global trends of antimicrobial prescribing quality. Antimicrobial stewardship (AMS) programmes have proven to be effective in improving prescribing quality and should be considered to specifically target improvements in metronidazole prescribing.

Pilot implementation study of a default genetic referral process for patients with young-onset colorectal cancer.

429 Background: Young-onset colorectal cancer (yCRC) diagnosed under age 50 is increasing at alarming rates, with &gt;75% of young-onset cases occurring in patients between 40-49 years old. Although national guidelines recommend germline genetic risk evaluations for all patients with yCRC, multiple studies have shown suboptimal rates of guideline-recommended genetic evaluations. Methods: We conducted a pilot implementation study of a default genetic referral process for patients diagnosed with CRC between ages 40-49 from 1/2019-4/2022 at five hospitals in an academic health system. Patients previously referred to genetics were analyzed as a historical comparator cohort. In the intervention cohort, a research coordinator notified patients and their oncologists of their eligibility for a default genetic referral via an electronic patient portal message or telephone call, after which all patients who did not opt out within two weeks were referred for genetic counseling, testing, and result disclosure as per usual care. The primary outcome was feasibility, defined as a ≥60% referral rate; secondary outcomes included the proportion of genetic referrals that were scheduled, completed, and resulted in testing within three months of referral. Semi-structured exit interviews were conducted with a subset of patients and oncologists to assess attitudes toward the default genetic referral process. Results: We identified 128 patients with yCRC; 75 (59%) had previously been referred to genetics and were assigned to the historical cohort. There were no significant differences in sex, race, or ethnicity between the historical and intervention cohorts. All 10 patients with mismatch repair deficient tumors had previously been referred to genetics. Of the 53 patients in the intervention cohort, 49 (92%) were referred to genetics after one oncologist opted out on behalf of an international patient due to financial concerns and three patients requested to discuss with their oncologist before being referred. Of the patients who were referred, 38 (78%) were scheduled, 22 (45%) completed genetic counseling, and 13 (27%) underwent testing within three months of referral. Reasons for failing to complete the germline genetic risk evaluation process included lack of interest, competing priorities, communication/scheduling challenges, and failure to return saliva-based genetic testing kits. In exit interviews with 10 patients who completed testing and 10 oncologists, participants reported finding the default genetic referral process to be acceptable and feasible to implement. Conclusions: A default genetic referral process is feasible and results in a high referral rate for patients with yCRC, but subsequent scheduling, evaluation, and testing rates remain suboptimal. Multilevel implementation strategies are needed to address the patient, clinician, and system barriers identified in this study. Clinical trial information: NCT05018156 .

Impact of Social Disparities on 5-Year Survival Rates in Pediatric Hematologic Malignancies.

Socioeconomic disparities exist in pediatric patients with hematologic malignancies, leading to suboptimal survival rates. Social determinants of health impact health outcomes, and in children, they may not only lead to worse survival outcomes but carry over into late effects in adult life. The social deprivation index (SDI) is a composite score using geographic county data to measure social determinants of health. Using the SDI, the purpose of the present study is to stratify survival outcomes in pediatric patients with hematologic malignancies based on area deprivation. A retrospective cohort study was performed using the national Surveillance, Epidemiology, and End Results oncology registry in the USA from 1975 to 2016 based on county-level data. Pediatric patients (≤18y old) with a diagnosis of leukemia or lymphoma based on the International Classification for Oncology, third edition (ICD-O-3) were used for inclusion criteria. Patients were grouped by cancer subtype for leukemia into acute lymphoblastic leukemia (ALL) and acute myeloid leukemia while for lymphoma into non-Hodgkin's lymphoma and Hodgkin's lymphoma. SDI scores were calculated for each patient and divided into quartiles, with Q1 being the lowest area of deprivation and Q4 being the highest, respectively. A total of 38,318 leukemia and lymphoma patients were included. Quartile data demonstrated stratification in survival based on area deprivation for ALL, with no survival differences in the other cancer subtypes. Patients with ALL from the most deprived area had a roughly 3% difference in both overall and cancer-specific morality at 5 years compared with the least deprived area. Disparities in pediatric patients with ALL represent a significant area for quality improvement. Social programs may have value in improving survival outcomes and could rely on metrics such as SDI.

Kinetic mechanisms of methane hydrate replacement and carbon dioxide hydrate reorganization

The carbon dioxide replacement is an ideal way to mine natural gas hydrates. However, current challenges of low replacement efficiency and immature technology compromise its application spectrum. This study aims to simulate the displacement of methane hydrate by carbon dioxide in a porous media system and verify the effect of water saturation on methane hydrate through experimental tests. By constructing a molecular dynamics model to investigate the replacement process of methane hydrate with carbon dioxide, the role of free water in this process was examined. Additionally, the study elucidated the factors contributing to suboptimal methane storage rate and low carbon dioxide recovery rate from a heat exchange perspective. The results show that methane replacement from methane hydrate can be divided into four stages. When the water saturation approach to hydrate saturation, and the temperature and pressure are between the phase curves of methane hydrate and carbon dioxide hydrate, the carbon dioxide storage rate and methane recovery rate can be significantly improved. The participation of free water can make the replacement more complete. The primary factor determining the replacement effect is the area of contact between carbon dioxide and methane hydrate, which is followed by the newly created carbon dioxide hydrate, which will impact the subsequent mass transfer. Although the heat released by the formation of carbon dioxide hydrate favor the replacement reaction proceed, most of the heat may get lost with the volatilization of carbon dioxide, resulting in the inability or incomplete decomposition of methane hydrate far away from free water. This research will surely have a profound impact on how hydrate replacement mining is monitored and managed as well as the ecosystem around it.