Virginia Commonwealth University Health System Research Articles

The Impact of Demographics and Comorbidities on Fall Incidence and Prevalence in Older Adults.

Falls among older adults are more than mere accidents; they are a silent epidemic, profoundly impacting the health and well-being of millions of older adults worldwide. This study examines the incidence and prevalence of falls among individuals aged 65 and above, focusing on the influence of demographic factors and comorbid conditions such as hypertension, diabetes mellitus, cancer, and obesity. A retrospective cohort study was conducted using data from the TriNetX network at Virginia Commonwealth University Health System (VCUHS) from 2019 to 2023. The study population included 16,400 individuals aged 65 and above who presented with fall-related trauma. Data on demographics, clinical diagnoses, procedures, and comorbid conditions were analyzed using descriptive statistics to evaluate the incidence and prevalence of falls. The mean age of the study population was 77.3 years, with a higher proportion of females (60.97%) compared to males (39.02%). Despite the larger number of female participants, incidence and prevalence of falls were highest among individuals aged 65-69 years, and fall rates were notably higher among males compared to females. This suggests that while fewer in number, males in our study experienced falls more frequently. Patients with hypertension had the highest incidence proportion (56.67%) and prevalence (75.75%) among comorbid conditions. Falls among older adults are significantly influenced by demographic factors and comorbid conditions. Hypertension, in particular, is associated with the highest fall risk. These findings highlight the need for targeted interventions to manage comorbidities and reduce fall risks among older adult patients.

Opportunity for Early De-escalation in Enterobacterales Bacteremia with Rapid Blood Culture Identification Technology

Background: The BioFire FilmArray Blood Culture Identification 2 (BCID2) Panel is used to identify organisms present in positive blood cultures within hours of detection at Virginia Commonwealth University Health System (VCUHS). BCID2 is also able to detect common resistance mechanisms including CTX-M, the most common extended-spectrum beta-lactamase (ESBL) in the United States, and several carbapenemases. The Antimicrobial Stewardship Program (ASP) at VCUHS established optimal treatment recommendations for each organism identified by BCID2 based on the detection of a resistance mechanism and local resistance patterns. The recommendation for the majority of Enterobacterales without a detected resistance mechanism is ceftriaxone. However, providers are often reluctant to de-escalate antibiotics without confirmed susceptibility testing, as there may be other mechanisms of antibiotic resistance in Gram-negative organisms. The objective of this evaluation was to measure the degree of congruence between BCID2 resistance mechanism detection and susceptibility testing by disk diffusion, and to validate the adequacy of the VCUHS ASP BCID2 treatment recommendations for Enterobacterales bacteremia. Methods: Patients with positive Enterobacterales BCID2 results from March 12 to June 19, 2023 were retrospectively identified. Organisms identified by BCID2 that were considered high-risk for clinically significant AmpC production due to an inducible AmpC gene (i.e., K. aerogenes, E. cloacae complex) were excluded. Results: A total of 270 results were included. The most commonly identified organism was E. coli (n = 139, 51.5%), followed by K. pneumoniae (n = 74, 27.4%). There were 27 (10%) isolates positive for CTX-M and 1 (0.4%) isolate positive for KPC. All CTX-M isolates were ceftriaxone resistant, and the KPC isolate was meropenem resistant. The remaining 242 isolates were negative for all resistance markers detected by BCID2. Of these, only 3 (1.2%) were resistant to ceftriaxone and notably, 8 (3.3%) were resistant to piperacillin/tazobactam. Overall, BCID2 CTX-M detection was 90% sensitive and 100% specific for predicting ceftriaxone resistance in Enterobacterales. Conclusion: CTX-M detection by BCID2 is highly sensitive and specific for predicting ceftriaxone resistance in Enterobacterales. CTX-M negative isolates were more often susceptible to ceftriaxone than to piperacillin/tazobactam, which is commonly used as empiric therapy for Gram-negative organisms at our institution. This highlights an excellent opportunity for safe and effective early de-escalation of antibiotics for treatment of Enterobacterales bacteremia.

'Burn and Push' technique: A novel robotic liver parenchymal transection technique.

Liver parenchymal transection during robotic liver resection (RLR) remains a significant challenge due to the limited range of specialised instruments. This study introduces our 'Burn and Push' technique as a novel approach to address these challenges. A retrospective analysis was conducted on 20 patients who underwent RLR using the 'Burn and Push' technique at Virginia Commonwealth University Health System from November 2021 to August 2023. The study evaluated peri- and post-operative outcomes. The median operation time was 241.5min (range, 90-620min), and the median blood loss was 100mL (range, 10-600mL). Major complications occurred in one case, with no instances of postoperative bleeding, bile leak, or liver failure. The 'Burn and Push' technique is a viable and efficient alternative for liver parenchymal transection in RLR. Further research with larger sample sizes and consideration of the learning curve is necessary to validate these findings.

Memory Loss and Missteps: Investigating Fall Risks in Alzheimer's and Dementia Patients.

Degenerative diseases such as Alzheimer's disease and dementia are significant health concerns among older adults in the United States, contributing substantially to the high incidence of falls in this population. This study aims to investigate the incidence and prevalence of falls among older adults diagnosed with Alzheimer's disease and dementia and explore the association between these conditions and the occurrence of traumatic brain injuries (TBIs). A retrospective cohort study was conducted using data from 17,000 older adults aged 65 and above, arrived at the hospital with fall related injuries, obtained from the TriNetX network at Virginia Commonwealth University Health System (VCUHS) between January 1, 2019, and December 31, 2023. Data included demographic information, diagnosis codes (ICD-10), and details on falls, Alzheimer's disease, dementia, and TBIs. Descriptive statistics and logistic regression analyses were performed using TriNetX analytical tools. Older adults with Alzheimer's disease (incidence proportion: 3.11%, prevalence: 4.81%) and dementia (incidence proportion: 12.46%, prevalence: 17.06%) had a significantly higher incidence of falls compared to those without these conditions. Females showed a slightly higher incidence of falls than males. Logistic regression analysis indicated that patients with Alzheimer's disease had a reduced risk of TBIs (OR = 0.765, 95% CI: 0.588-0.996, p = 0.047), while those with unspecified dementia had an increased risk (OR = 1.161, 95% CI: 1.002-1.346, p = 0.047). Our study reveals a higher risk of falls and traumatic brain injuries (TBIs) in older adults with dementia compared to those with Alzheimer's disease. These findings underscore the need for targeted fall prevention strategies and educational programs for caregivers.

Racial disparities in ALS diagnostic delay: a single center's experience and review of potential contributing factors.

Outcomes for amyotrophic lateral sclerosis (ALS) patients are improved with prompt diagnosis, earlier initiation of disease-modifying treatments, and participation in a multidisciplinary clinic. We studied diagnostic delay and disease severity at time of clinic presentation between Black and non-Hispanic Caucasian ALS patients. We performed a retrospective analysis of non-Hispanic Caucasian and Black ALS patients seen in the Virginia Commonwealth University Health System multidisciplinary ALS clinic between 2017 and 2023. Diagnostic delay, ALS Functional Rating Scale-Revised (ALSFRS-R) and upright forced vital capacity (FVC) scores at baseline appointment were collected. Patient's distance from clinic and affluency of residential neighborhood were evaluated. We analyzed 172 non-Hispanic Caucasian and 33 Black ALS patients. Black patients had a 64% increase in diagnostic delay compared to non-Hispanic Caucasian patients. Black patients had a lower performance on ALSFRS-R (5.3 points, p < 0.001) and FVC (17.9 percentage points p < 0.001) at time of first clinic visit. Black patients lived closer to clinic, with higher proportion living in the city of Richmond, but in less affluent areas with lower median house income ($55,300 ± 22,600 vs $69,900 ± 23,700). Our findings demonstrate a large racial difference in ALS diagnostic delay, and greater disease severity and lower respiratory function at time of diagnosis for Black ALS patients. Delay in diagnosis prolongs access to disease-modifying therapies, multidisciplinary care, durable medical equipment, and respiratory and nutritional support. Potential sources of these racial disparities include providers' implicit bias and structural racism.

The relationship between palliative radiotherapy and opioid prescribing patterns among patients with metastatic cancer.

While randomized trials have established that palliative radiotherapy, especially to bone, can improve qualitative measures of pain, its quantitative relationship to opioid prescribing patterns has remained underexplored. We aimed to identify the association of palliative radiotherapy on opioid prescriptions received among patients with metastatic cancer. The Virginia Commonwealth University Institutional Review Board approved retrospective analysis extracted prescription data from all adult patients with metastatic cancer who underwent outpatient palliative external beam radiation therapy at Virginia Commonwealth University Health System from 2008-2018. Institutional prescribing data were used to calculate the average opioid oral morphine milligram equivalent (MME) dose 30, 60 and 90 days both before and after radiotherapy. Univariate and bivariate ordinary least squares (OLS) regression models were used to estimate the relationship of MME changes with clinical, radiation-related, and demographic patient factors. A total of 182 patients met inclusion criteria. Overall, patients required higher opioid doses after radiotherapy, with mean MME 30, 60, and 90 days prior to radiotherapy of 24.6, 20.2, and 16.8 mg, respectively; which increased to 62.9, 77.7 and 82.4 mg post-radiation therapy (P<0.01). Multivariate OLS models predicting the change of MME 60 days pre- and post-radiation treatment showed that younger age and comorbid depression predicted increased MME after radiotherapy. Patients with metastatic cancer face a relatively high opioid burden, which increases over time, even among those who receive palliative radiation therapy. Patients who are younger and have comorbid depression may have a higher risk of increased opioid burden after radiotherapy.

Abstract C098: "Am I at risk for cervical cancer?": Racial disparity implications of an unexpected relationship between chronic conditions and precancerous lesions

Abstract Objective: Cervical cancer is a highly preventable malignancy caused by HPV that begins with the development of precancerous lesions (high risk cervical intraepithelial neoplasia grades 2 or 3 - hrCIN). As cancer is a metabolic disease, individuals with metabolic conditions such as diabetes, high cholesterol (hcho) and high blood pressure (hbp) may be at higher risk of developing hrCIN. Given the higher prevalence among Black women, we sought to determine whether these metabolic conditions increase the risk of hrCIN differentially by race. Methods: We used data from hospital and physician billing claims for any CIN diagnosis occurring at the Virginia Commonwealth University Health System (VCUHS) from 01/01/2014 through 12/04/2021, along with respective clinical and sociodemographic characteristics at the time of diagnosis. We estimated the risk of high-grade dysplasia (CIN2+ versus CIN1) among women with various metabolic diseases, using logistic regression (LR) with a backward selection approach (removing terms with p ≥ 0.2 and adding those with p &amp;lt; 0.1) to identify most relevant confounding factors. Results: There were 2,761 women diagnosed with CIN 1, 2, 3, and unspecified dysplasia of the cervix uteri with respective prevalence of 30%, 45%, 11%, and 14%. The prevalence of hrCIN did not vary by race (48% versus 52% for non-Latina (nL)-whites versus nL-Blacks respectively). Of the variables included in the LR model (age, marital status, religion, preferred language, insurance status, Body Mass Index, HIV, HPV, presence of bacterial vaginosis, hypertension, cholesterol, diabetes, pulmonary conditions, arthritis, heart conditions, pregnancy status, parity, smoking, alcohol, and previous cancer diagnoses), only pregnancy status, diabetes, hypertension, cholesterol, insurance, language, pulmonary conditions, and HPV remained in the final LR model. We identified an interaction between hypertension and cholesterol (p=0.03) where the odds of a hrCIN among women with both, hypertension, and cholesterol, were more than twice compared to women with neither comorbidity (OR=2.2, 95%CI: 1.1, 4.3). Stratified by race, the elevated risk of hrCIN was only significant among nL-Black women (p=0.05, OR=2.9, 95%CI: 1.1, 8.6). Conclusions: Despite no apparent difference in the incidence of hrCIN by race in this dataset, our analysis revealed an excess risk of hrCIN that was only present for Black women with both hypertension and hypercholesterolemia. These comorbidities are both overrepresented in nL-Blacks and are associated with low grade systemic inflammation, which may promote HPV persistence and progression to hrCIN. If replicable, this association deserves further investigation to assess its biological underpinnings and potential as a point of intervention to reduce the risk of CIN progression and cervical cancer. Citation Format: Shreya R. Raman, Stephanie A. Sullivan, Robert A. Winn, Katherine Y. Tossas. "Am I at risk for cervical cancer?": Racial disparity implications of an unexpected relationship between chronic conditions and precancerous lesions [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr C098.

Abstract 446: Outcome of cancer patients with COVID-19: the VCU experience

Abstract Purpose: COVID-19 has deeply impacted the care and prognosis of those with preexisting acute and chronic conditions including cancer. The purpose of this study is to identify risk factors contributing to death from COVID-19 infection in the cancer population at Virginia Commonwealth University Health System (VCUHS). Materials and Methods: 507 patients were evaluated that had a diagnosis of any solid or hematologic malignancy and admitted to the inpatient service at VCUHS while having a COVID-19 PCR positive test between February 2020 and June 2021. Patient characteristics as well as comorbidities, transplant status, ventilator dependence, intensive care admission, and malignancy type were recorded. Death was recorded as being due to COVID-19 or COVID-19 complications. Logistic regression model was used to determine odds ratio (OR) of death from COVID 19. Results were listed with respective OR both unadjusted and adjusted for age, race, sex, body mass index (BMI), and comorbidities including diabetes, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), and chronic kidney disease (CKD). Results: Of the 507 patients, 37 experienced death (7.3%). Only 40 patients required ICU admission (7.9%) and 24 required ventilator support (4.7%). Increased age per 5-year increments was associated with increased risk of death in adjusted and unadjusted analysis (OR 1.30 (1.06,1.63) and 1.26 (1.10,1.46)). There was no significant risk of death in either adjusted or unadjusted analysis between Caucasian, African American, Asian or unspecified races. When not adjusted, COPD (OR 2.56, 1.28-5.11), CAD (OR 2.69, 1.36-5.32), and CKD (OR 2.14, 1.09-4.21) were all shown to have significant risk of death. However, when adjusted, there were no significant difference in odds ratio between patients with diabetes, CAD, COPD, and CKD. When adjusted, malignancies of central nervous system (CNS) (OR 70.30, 2.18-1520.3), hematologic (OR 4.79, 1.05-30.77), and head and neck (OR 11.64, 1.58-100.01) were at increased risk of death; while female associated malignancies, genitourinary (GU), lung, connective tissue, and those with multiple primary malignancies did not have significant risk. Ventilatory dependence did increase mortality risk (OR 50.54, 7.62,459.7), while transplant status and intensive care unit admission did not. Conclusions: Based on the results from this study, there is an increased risk of death from COVID-19 infections in several variables in the cancer population at VCUHS. Age, ventilator dependence, CNS, hematologic, and head and neck malignancies were all associated with increased mortality. Further evaluation will include the 13 other patients in which data was not yet available. Other variables that will be evaluated are COVID treatments, vaccination status, antibody formation, cancer treatment modality used within 30 days of COVID diagnosis, and lab values including cell counts and inflammatory markers. Citation Format: Patrick J. Willard, Temmy Olasehinde, Naji Bou Zeid, Edem Defor, Victor Yazbeck, Dipankar Bandyopadhyay. Outcome of cancer patients with COVID-19: the VCU experience [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 446.

Abstract 2208: Unexpected pattern in estimated prevalence of precancerous cervical lesions at a safety net hospital in Virginia: A case for epidemiologic surveillance

Abstract Objectives: High-grade squamous lesions of the cervix, (Cervical Intraepithelial Neoplasia (CIN) grade 2 and 3), are concerning, common, and costly precancerous findings, particularly for safety net hospitals who provide healthcare regardless of finances or insurance status. Epidemiologic surveillance of these lesions is uncommon but might be useful to guide preventive interventions. We sought to estimate the prevalence of CIN 2/3 and its racial and ethnic distribution, accounting for patient’s clinical and sociodemographic characteristics. Methods: We used data from hospital and physician billing claims for any CIN diagnosis occurring at the Virginia Commonwealth University Health System (VCUHS) from 01/01/2016 through 12/31/2020, along with respective clinical and sociodemographic characteristics at the time of diagnosis. We estimated average adjusted prevalence of CIN 2/3 lesions by race and ethnicity, from average marginal effects, after selecting most relevant patient factors from a logistic regression (LR) using backward selection (removing terms with p ≥ 0.2 and adding those with p &amp;lt; 0.1). Results: There were 1,538 women diagnosed with CIN 1, 2, 3, and unspecified dysplasia of the cervix uteri with respective prevalence of 45%, 14%, 12%, and 30%. CIN2/3 prevalence (26%) varied by race and ethnicity: Asians (39%) &amp;gt; Latinas (32%) &amp;gt; Whites (28%) &amp;gt;Blacks (23%) &amp;gt; Other (20%). Of the variables included in the LR model (age, marital status, religion, preferred language, insurance status, Body Mass Index, HIV, HPV, presence of bacterial vaginosis, hypertension, cholesterol, diabetes, pulmonary conditions, arthritis, heart conditions, pregnancy status, parity, smoking, alcohol, and previous cancer diagnoses), only age, diabetes, pulmonary conditions, smoking, and heart disease remained in the final LR model. The estimated average adjusted prevalence of a CIN 2/3 diagnosis remained highest for Asian women (35%, 95%CI: 17-52%), followed by Latinx (28%, 95%CI: 19-37%), Whites (25%, 95%CI 22-29%), Blacks (23%, 95%CI: 20-27%), and other (18%, 95%CI: 9-26%). Conclusions: The higher CIN 2/3 prevalence estimates among Asian women relative to other races and ethnicities is unexpected, as it does not align with current distribution of cervical cancer diagnoses at VCUHS (only 3% Asian), nor with the patterns of cervical cancer incidence and mortality rates in Virginia and in the United States, where Asian women have the lowest incidence and mortality. However, it potentially suggests a higher rate of regression, a finding supported by at least one surveillance study with similar findings. Citation Format: Shreya R. Raman, Stephanie A. Sullivan, Katherine Y. Tossas. Unexpected pattern in estimated prevalence of precancerous cervical lesions at a safety net hospital in Virginia: A case for epidemiologic surveillance [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2208.

Editorial: Think again.

Department of Anesthesiology and Critical Care, Virginia Commonwealth University, Richmond, Virginia, USA Correspondence to Alice Coombs, MD, MPA, FCCP, Department of Anesthesiology, Virginia Commonwealth University Health System, 1200 East Broad Street, 7th Floor, North Wing, Box 980695, Richmond, VA 23298-09695, USA. Tel: +1 804 512 3865; e-mail: [email protected]

Changes in obesity and diabetes severity during the COVID-19 pandemic at Virginia Commonwealth University Health System

Abstract Introduction: The COVID-19 pandemic significantly changed the lives of millions of people in the USA, preventing them from continuing their regular lifestyles. This study examined the manifestation of “Covibesity” in the patient population of the Virginia Commonwealth University (VCU) Health System and explored the effects of the distraction caused by the pandemic in the management of diabetes disease. Methods: This project analyzed body mass index (BMI) rates of the general adult patient population at the VCU Health System during the COVID-19 pandemic compared to prior years. The project also investigated the changes in the severity of diabetes cases treated at the VCU Health System by comparing HbA1c laboratory results and the number of diabetes-related emergency department (ED) visits before and during the pandemic. The results were stratified by age, gender, and race to examine subpopulations. Results: The mean BMI for the general patient population increased from 2018 to 2019 but decreased in 2020. The mean HbA1c measurements for the diabetic patient population increased from 2018 to 2020, while the number of ED visits declined in 2020 for the same population. When stratified by race, the trends in the outcomes largely reflected those of the overall mean. The African American population had a higher mean BMI, HbA1c, and number of ED visits than other races, but showed the same temporal behavior to the overall mean.

Nursing Students Behind Bars

With a large incarcerated patient population in the United States, there is a unique potential for clinical learning for undergraduate nursing students with this population. The Virginia Commonwealth University (VCU) School of Nursing and VCU Health System have created a unique partnership in which baccalaureate nursing students complete their first clinical rotation on VCU Health System's Secure Care Unit (SCU). At the conclusion of their semester, baccalaureate students assigned to the SCU for the fundamentals clinical were asked to provide feedback on their experiences. Both challenges and positive outcomes were identified by students who completed their first clinical rotation providing care to this unique population. The formation of this relationship between the VCU School of Nursing and the VCU Health System's SCU is helping to meet patient, student, and clinical unit needs and also making a positive impact on the stakeholders involved. [J Nurs Educ. 2021;60(8):470-471.].

Enhancing Adherence to Prescribed Opioids Using a Mobile-Based App: A Feasibility Study in Non-Cancer Pain

Background: Nonadherence (overutilization and underutilization) to prescribed opioids underlies the current US opioid epidemic/crisis. Methods to measure opioid adherence, including patient recall, pill counts, refill rates, biological monitoring such as urine toxicology, and electronic monitoring such as MEMS Caps, each have limitations or are only proxy measures. While not perfect, apps which both collect instantaneous patient reports of utilization using reminders, and have the potential to encourage appropriate behavior, are gaining popularity as a way to monitor adherence. We were interested to develop such an app to monitor opioid adherence, and report here feasibility of a mobile monitoring and reporting system that would provide an accurate unbiased screening tool to systematically analyze opioid adherence simultaneous to pain measures,Methods: We developed a mobile-based application, OpPill, for IOS and android platforms. Development and testing consisted of deep mixed methods research on pain behavior and opioid use among SCD patients (n=21) to determine the application content and/or structure. The Application was used by Sickle Cell Disease patients (n=30) at the Virginia commonwealth university health system. The Mobile Applications Rating scale: A New and validated Tool for Assessing the Quality of Health Mobile Apps for engagement, functionality, aesthetics, information quality, subjective quality, relevance and overall impact was administered post usage to evaluate the Application.Results: A total of 30 patients were tested. Patients were equally divided among males and females, had a high school to graduate level education, with a majority having some college education. The majority of the population found the application to be relevant for their care. When asked to mark all the items they thought the application was designed to do, 37% indicated that it was aimed at improving their physical health, and 37% thought it was designed to help them set goals, while 29.6% and 22.2% said respectively that it helped them feel happy/healthy and reduce negative emotions. In regards to the targeted population, patients where asked if the content was appropriate for sickle cell and the majority said it was well-targeted, with negligible issues (88.8%). Study participants were asked if they would recommend this application to people with sickle cell disease and 100% said they would recommend the application. Patients were also asked to report on the completeness of information within the app, the majority 96% reported on the application's completeness while 4% estimated the information to be minimal or overwhelming. The quality of information as it pertains to sickle cell patients was reported to be relevant (91.7%) while 8.3% found the application to be poorly relevant to sickle cell disease. The application's performance was positively rated at 100% with ease of use positively rated at 91.7%. Most participants (85.7%) found the application to be interesting to use while 74% found it entertaining. All users found the application's navigation to be logical and accurate with consistent and intuitive gestural design.When asked how many times patients thought they would use the application in the next 12 months, results showed 24% would use it over 50 times, 36% would use it somewhere between 10-50 times and 40% would only use it 3-10 times. Some patients reported that they would pay for the application (24%) while 44% said they might pay and 32% reported that they would not pay for this application. On a scale of 1 to 5 with 1 being the lowest and 5 being the highest, mean engagement, functionality, Aesthetics and information scores were calculated and yielded the following results: mean engagement score: 3.96, mean functionality score: 4.54, mean aesthetics score: 3.96 and mean information score: 3.91.Conclusions/Future work: We found feasibility of use of a smartphone application specifically targeted to monitor opioid use and behavior in patients with sickle cell disease (SCD)-associated pain. Results are limited in that results are self-reported. Future work should include validation of reported opioid use from the app. DisclosuresNo relevant conflicts of interest to declare.

Time of Eating and Cardiorespiratory Fitness in Patients with Heart Failure With Preserved Ejection Fraction and Obesity

Abstract Objectives To examine the impact of eating prior to or after the mean time of evening meal on cardiorespiratory fitness (CRF) in patients with heart failure with preserved ejection fraction (HFpEF) and concomitant obesity. Methods Twelve patients with HFpEF (left ventricular ejection fraction ≥50%) and obesity (body mass index (BMI) ≥30 kg/m2 or fat mass % (FM%) ≥25% men or ≥35% women) underwent a maximal cardiopulmonary exercise test to obtain peak oxygen consumption (VO2) relative to body weight (ml•kg−1•min−1) and exercise time. Bioelectrical impedance analysis was used to measure FM%. Mean evening meal time was established as 7:25 (SD = 2.1 hours) post meridiem (PM) by averaging three consecutive five-pass 24-hour dietary recalls. Participants were classified by having intake prior to (Group I) or after (Group II) 7:25 PM. Total caloric intake and physical activity were obtained at baseline. Differences between groups were assessed with Mann-Whitney U and Spearman's rank correlation was used to examine associations. Results Participants were 64 (52–65) years of age, 75% female, 58% black, and had a BMI of 36.6 (34.2–41.6) kg/m2 with a FM of 42.5 (36.1–45.5)%. Median peak VO2 was 14.6 (11–19.6) ml•kg−1•min−1 and exercise time was 566 (453–786) seconds. Group II had a significantly greater peak VO2 (Group 1: 10.4 (9.5–15.2) ml•kg−1•min−1; Group II: 14.8 (14.4–23.4) ml•kg−1•min−1, P = 0.028) and exercise time (Group 1: 452 (360–505) seconds; Group II: 662 (578–846) seconds, P = 0.007). Physical activity, body composition, age and total daily calories did not differ between groups (all P &amp;gt; 0.1). On univariate analysis, both peak VO2 (r = 0.736, P = 0.006) and exercise time (r = 0.767, P = 0.004) demonstrated a favorable association with time of eating. Conclusions Caloric intake after the mean time of evening meal was associated with better CRF in patients with HFpEF and obesity. Providing nutrients later may help avoid fasting-related stress associated with cardiac metabolic abnormalities found in HF. Prospective randomized controlled trials examining the effects of later evening meal time in patients with HFpEF and obesity are warranted. Funding Sources Study funding was obtained through the American Heart Association, National Institutes of Health and Virginia Commonwealth University Health System.

In memoriam: Robert T. Leshner, MD

In memoriam: <scp>Robert T. Leshner</scp>, <scp>MD</scp>

Experiences in outpatient parenteral antimicrobial therapy (OPAT): Barriers and challenges from the front lines.

Outpatient parenteral antimicrobial therapy (OPAT) is now the standard of care for managing patients who no longer need inpatient care but require prolonged intravenous antimicrobial therapy. OPAT increases patient satisfaction, reduces the lengths of hospital stay, lowers emergency department readmission rates, and decreases total healthcare spending. To investigate Virginia Commonwealth University Health System's experience with OPAT and to highlight the obstacles patients and clinicians face when navigating and utilizing this program. We conducted this descriptive study at a large, academic, tertiary-care hospital in Central Virginia. We performed manual reviews of electronic medical records of 602 patient, and we evaluated the records of those receiving OPAT between 2017 and 2020. Reviews included antimicrobial agents, diagnoses requiring OPAT, adverse effects related to antimicrobials, adverse effects related to peripherally inserted central catheters (PICC), readmission rate, discharge destination, and death. We evaluated our program with descriptive statistics. Among 602 patients who received OPAT, most were diagnosed with bacteremia or musculoskeletal infections. Patients were either discharged home or to another healthcare facility, with the former comprising most of the rehospitalizations. Ertapenem and vancomycin were associated with the most adverse drug events among our cohort. Elevated transaminase levels were noted in 23% of patients. The rate of PICC-line adverse events in this study population was 0.05%. Our findings highlight the barriers and challenges that patients and providers face when receiving OPAT, and they can inform efforts to improve patient clinical outcomes.

858. Inter-rater Reliability of Hand Hygiene Observers with an Electronic Monitoring System

BackgroundHand hygiene (HH) is the bedrock of infection prevention. Knowing the limitations of hand hygiene observers, Virginia Commonwealth University Health System invested in technology to remotely monitor health care workers’s (HCW) HH. Each hand sanitizer and soap dispenser in the patient care areas has a sensor, as well as each patient’s bed and each HCW. As the HCW moves around the environment, the sensors detect whether or not HH was performed for each opportunity.MethodsWhile monitoring HH via observations, we compared the manual observations and the technologic hand hygiene observations.ResultsOf 31 witnessed and manually recorded HH observations, 30 were noted in the electronic system (96.7% correspondence). There was only one witnessed opportunity that the technology failed to capture, when the staff member was performing hand hygiene while standing in the doorway talking to the nurse inside the room. There were multiple missed opportunities for HH while in patient rooms, as defined by the WHO’s Five Moments.ConclusionThere was excellent correspondence between the manual observations and the HH technology in this study. There is significant limitation in what an observer can do, while the HH technology will average around 35,000 ‘observations’ on a daily basis and is capable of capturing more of the 5 moments of HH. We have previously noted interference in the wireless technology in the healthcare environment. However, failure of providers to perform HH when indicated overshadow the failures of technology to capture HH that is performed. Better understanding of the indications for HH in accordance with the WHO 5 Moments may improve provider trust in the technology.Disclosures All Authors: No reported disclosures

Barriers to Attendance of Prenatal and Well-Child Visits.

Prenatal care (PNC) and well child visit (WCV) attendance are associated with improved health outcomes. We aimed to determine if the factors affecting maternal and child attendance are similar or different. We conducted a retrospective case control study at Virginia Commonwealth University Health System. We used the Adequacy of Prenatal Care Utilization Index and the American Academy of Pediatrics recommendations to assess the adequacy of PNC and WCV attendance, respectively. Mothers with less than 50% visit adherence or initiation after 5 months gestation were eligible as cases and those with 80% or more adherence and initiation before 5 months were eligible as controls. Children in the lowest quintile of adherence were eligible as cases and those with 80% or more adherence were eligible as controls. Cases and controls were randomly selected at a 1:2 ratio from the eligible subjects and frequency matched on birth month. In adjusted analyses, mothers and children who were publicly insured or who were uninsured had higher odds of poor preventive visit attendance. Mothers who experienced intimate partner violence and had more living children were more likely to have poor attendance. Children whose mothers had younger age, greater number of pregnancies and transportation difficulties had poorer attendance. While lack of insurance and public insurance remained significantly associated with both poor PNC and WCV attendance, other factors varied between groups. Expanding eligibility requirements and streamlining enrollment and renewal processes may improve two generations of preventive visit attendance.

Adverse Childhood Experiences, Maternal/Fetal Attachment, and Maternal Mental Health.

Background: This pilot study investigated the potential impact of exposure to childhood adversity on variables known to be related to posttraumatic stress (including attachment, mental health, and perceived stress) in a clinic sample of pregnant women.Materials and Methods: Participants consisted of 101 pregnant women recruited from the Virginia Commonwealth University Health System in Richmond, VA. All participants completed the Adverse Childhood Experience (ACE) questionnaire, Parental Bonding Instrument, Maternal Fetal Attachment Scale, Posttraumatic Stress Disorder (PTSD) Checklist, Symptom Checklist, and the Perceived Stress Scale.Results: Increased exposure to ACEs was negatively associated with retrospective report of viewing one's mother and father as caring and involved. ACE exposure was a statistically significant predictor of viewing one's mother and father as intrusive and controlling. ACEs were positively associated with self-reported PTSD symptoms, depressive and anxious symptomatology, and perceived stress. No direct effect of adverse childhood events on maternal/fetal attachment was found.Conclusions: ACE associations are discussed in terms of study methodology and needs for future research. Providers may consider incorporating the ACE questionnaire to identify exposure to childhood adversity and events that may increase an individual's risk for toxic stress and negative health outcomes.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.