Search

Diabetes mellitus is a common endocrinopathy in dogs and in most cases is analogous to type 1 diabetes mellitus (T1DM) in humans.

BACKGROUND: Modified Early Warning Systems (MEWS) scores offer proxies for morbidity and mortality that are easily acquired, but there are limited data on what changing MEWS scores within the ED indicate. We examined the correlation of changing MEWS scores during resuscitation in the ED and in-hospital morbidity and mortality. METHODS: We conducted a retrospective analysis on medical ED patients with simplified MEWS scores (without urine output or mental status) admitted to a single academic tertiary care center over one year. Triage-to-Last delta MEWS score and Triage-to-Max delta MEWS scores were calculated and correlated to in-hospital mortality, ICU admission, length of stay (LOS) and diagnosis of sepsis. RESULTS: Our analysis included 8,322 ED patients with an ICU admission rate of 17% and a mortality rate of 2%. Every point of worsened MEWS after triage was more strongly associated with all-cause mortality (OR 2.41, 95% CI 1.96 – 2.97) than triage MEWS alone (OR 1.33, 95% CI 1.23–1.44; p

Objective The objective of this study was to assess the clinical and financial impact of a quality improvement project that utilized a modified Early Warning Score (mEWS)-based clinical decision support intervention targeting early recognition of sepsis decompensation. Materials and Methods We conducted a retrospective, interrupted time series study on all adult patients who received a diagnosis of sepsis and were exposed to an acute care floor with the intervention. Primary outcomes (total direct cost, length of stay [LOS], and mortality) were aggregated for each study month for the post-intervention period (March 1, 2016–February 28, 2017, n = 2118 visits) and compared to the pre-intervention period (November 1, 2014–October 31, 2015, n = 1546 visits). Results The intervention was associated with a decrease in median total direct cost and hospital LOS by 23% (P = .047) and .63 days (P = .059), respectively. There was no significant change in mortality. Discussion The implementation of an mEWS-based clinical decision support system in eight acute care floors at an academic medical center was associated with reduced total direct cost and LOS for patients hospitalized with sepsis. This was seen without an associated increase in intensive care unit utilization or broad-spectrum antibiotic use. Conclusion An automated sepsis decompensation detection system has the potential to improve clinical and financial outcomes such as LOS and total direct cost. Further evaluation is needed to validate generalizability and to understand the relative importance of individual elements of the intervention.

Individuals with autism spectrum disorder (ASD) exhibit an increased burden of de novo mutations (DNMs) in a broadening range of genes. While these studies have implicated hundreds of genes in ASD pathogenesis, which DNMs cause functional consequences in vivo remains unclear. We functionally test the effects of ASD missense DNMs using Drosophila through “humanization” rescue and overexpression-based strategies. We examine 79 ASD variants in 74 genes identified in the Simons Simplex Collection and find 38% of them to cause functional alterations. Moreover, we identify GLRA2 as the cause of a spectrum of neurodevelopmental phenotypes beyond ASD in 13 previously undiagnosed subjects. Functional characterization of variants in ASD candidate genes points to conserved neurobiological mechanisms and facilitates gene discovery for rare neurodevelopmental diseases.

SummaryIndividuals with autism spectrum disorders (ASD) exhibit an increased burden ofde novovariants in a broadening range of genes. We functionally tested the effects of ASD missense variants usingDrosophilathrough ‘humanization’ rescue and overexpression-based strategies. We studied 79 ASD variants in 74 genes identified in the Simons Simplex Collection and found 38% of them caused functional alterations. Moreover, we identifiedGLRA2as the cause of a spectrum of neurodevelopmental phenotypes beyond ASD in eight previously undiagnosed subjects. Functional characterization of variants in ASD candidate genes point to conserved neurobiological mechanisms and facilitates gene discovery for rare neurodevelopmental diseases.

Background Dexmedetomidine (DEX) is a highly selective α-2 agonist with many desirable effects including analgesia, improvement of hemodynamic stability, and potential myocardial and renal protection. The aim of this study was to investigate the effect of DEX on patients undergoing off-pump coronary artery bypass (OPCAB) grafting with regard to less pain medication, earlier extubation, faster transfer to normal ward, and cardiac protection. Patients and Methods From January 2012 to March 2015, 464 patients receiving OPCAB were included for retrospective analysis. After propensity matching (1:1), two groups (DEX vs. propofol, n = 129) could be compared. Continuous and categorical variables were reported as mean ± standard deviation or percentages, and compared with the chi-square test and the Mann–Whitney's test, respectively. Results In the DEX group, less use of pain medication in the initial phase at intensive care unit was observed. During the first 2 hours, DEX patients received more nicomorphine (DEX 8 ± 3.2 mg vs. propofol 6 ± 4 mg, p Conclusion Early postoperative DEX application supports the fast-track strategy in patients after OPCAB through enabling rapid extubation, effective pain control, and reduced occurrence of new-onset AF. We are confident to give precedence to DEX over propofol as the new routine medication during postoperative patient transfer.

Background: Pleural effusions constitute one of the most frequent pathologies encountered in the pulmonary service of Maputo Central Hospital (MCH) in Mozambique. Bleomycin and talc are commonly used for pleurodesis, but cost prohibitive, therefore we aimed to retrospectively compare the efficacy and safety of sodium hydroxide (NaOH) with bleomycin for pleurodesis. Methods: Case records of pleurodesis using bleomycin and NaOH from 2002 to 2013 were reviewed. Standard of care for pleurodesis for recurrent pleural effusions at MCH was developed using the materials available. NaOH remained the agent of choice until 2006 when bleomycin became available. Clinical data regarding general complications, rate of success and lung expansion were noted for every patient who underwent pleurodesis at MCH during this time frame. Results: Review of pleurodesis at MCH revealed 24 cases using bleomycin and 23 cases using NaOH as the sclerosing agent. Patient characteristics were balanced between the two groups with majority of pleural effusions malignant in etiology. Conclusions: There was no statistically significant difference between the use of bleomycin and NaOH as defined by lung expansion. General complications were observed less frequently in 2 (10%) of patients treated with NaOH compared with 8 (38%) of patients using bleomycin. Only three patients presented with recurrent pleural effusion after pleurodesis with NaOH. NaOH may offer a low cost alternative sclerosing agent for resource limited areas.

The organization and delivery of a curriculum is the responsibility of the faculty in educational institutions. Curricular revision is often a hotly debated topic in any college faculty. At the University of Illinois, a 2006 mandate for curriculum modernization from the American Veterinary Medical Association Council on Education provided impetus for a long-discussed curricular revision. After two iterations and a lengthy development process, a new curriculum was gradually implemented at Illinois with the August 2009 matriculation of the Class of 2013. The goals of the revision included earlier clinical exposure for veterinary students through introductions to clinical rotations in years 1 to 3 and an integrated body systems approach in lecture/laboratory courses. A new Clinical Skills Learning Center facilitates development of clinical skills earlier in the curriculum and promotes the development of those skills throughout all 4 years of the curriculum. New outcomes assessments include comprehensive written examinations and Objective Structured Clinical Examinations (OSCEs) in years 2 and 3. Curriculum management, including grading of clinical rotations in all 4 years, is achieved through a commercially available software package. For the past 5 years, when candidates were asked why they chose to apply to Illinois, the new curriculum (27.4%) was the most common answer given during interviews. The Illinois revision has resulted in measurably increased veterinary student self-confidence (p

The SoLid experiment aims to measure neutrino oscillation at a baseline of 6.4 m from the BR2 nuclear reactor in Belgium. Anti-neutrinos interact via inverse beta decay (IBD), resulting in a positron and neutron signal that are correlated in time and space. The detector operates in a surface building, with modest shielding, and relies on extremely efficient online rejection of backgrounds in order to identify these interactions. A novel detector design has been developed using 12800 5 cm cubes for high segmentation. Each cube is formed of a sandwich of two scintillators, PVT and 6LiF:ZnS(Ag), allowing the detection and identification of positrons and neutrons respectively. The active volume of the detector is an array of cubes measuring 80× 80× 250 cm (corresponding to a fiducial mass of 1.6 T), which is read out in layers using two dimensional arrays of wavelength shifting fibres and silicon photomultipliers, for a total of 3200 readout channels. Signals are recorded with 14 bit resolution, and at 40 MHz sampling frequency, for a total raw data rate of over 2 Tbit/s. In this paper, we describe a novel readout and trigger system built for the experiment, that satisfies requirements on: compactness, low power, high performance, and very low cost per channel. The system uses a combination of high price-performance FPGAs with a gigabit Ethernet based readout system, and its total power consumption is under 1 kW. The use of zero suppression techniques, combined with pulse shape discrimination trigger algorithms to detect neutrons, results in an online data reduction factor of around 10000. The neutron trigger is combined with a large per-channel history time buffer, allowing for unbiased positron detection. The system was commissioned in late 2017, with successful physics data taking established in early 2018. The SoLid experiment aims to measure neutrino oscillation at a baseline of 6.4 m from the BR2 nuclear reactor in Belgium. Anti-neutrinos interact via inverse beta decay (IBD), resulting in a positron and neutron signal that are correlated in time and space. The detector operates in a surface building, with modest shielding, and relies on extremely efficient online rejection of backgrounds in order to identify these interactions. A novel detector design has been developed using 12800 5 cm cubes for high segmentation. Each cube is formed of a sandwich of two scintillators, PVT and 6LiF:ZnS(Ag), allowing the detection and identification of positrons and neutrons respectively. The active volume of the detector is an array of cubes measuring 80x80x250 cm (corresponding to a fiducial mass of 1.6 T), which is read out in layers using two dimensional arrays of wavelength shifting fibres and silicon photomultipliers, for a total of 3200 readout channels. Signals are recorded with 14 bit resolution, and at 40 MHz sampling frequency, for a total raw data rate of over 2 Tbit/s. In this paper, we describe a novel readout and trigger system built for the experiment, that satisfies requirements on: compactness, low power, high performance, and very low cost per channel. The system uses a combination of high price-performance FPGAs with a gigabit Ethernet based readout system, and its total power consumption is under 1 kW. The use of zero suppression techniques, combined with pulse shape discrimination trigger algorithms to detect neutrons, results in an online data reduction factor of around 10000. The neutron trigger is combined with a large per-channel history time buffer, allowing for unbiased positron detection. The system was commissioned in late 2017, with successful physics data taking established in early 2018.

Summary Mitochondria are essential in long axons to provide metabolic support and sustain neuron integrity. A healthy mitochondrial pool is maintained by biogenesis, transport, mitophagy, fission, and fusion, but how these events are regulated in axons is not well defined. Here, we show that the Drosophila glutathione S-transferase (GST) Gfzf prevents mitochondrial hyperfusion in axons. Gfzf loss altered redox balance between glutathione (GSH) and oxidized glutathione (GSSG) and initiated mitochondrial fusion through the coordinated action of Mfn and Opa1. Gfzf functioned epistatically with the thioredoxin peroxidase Jafrac1 and the thioredoxin reductase 1 TrxR-1 to regulate mitochondrial dynamics. Altering GSH:GSSG ratios in mouse primary neurons in vitro also induced hyperfusion. Mitochondrial changes caused deficits in trafficking, the metabolome, and neuronal physiology. Changes in GSH and oxidative state are associated with neurodegenerative diseases like Alzheimer’s. Our demonstration that GSTs are key in vivo regulators of axonal mitochondrial length and number provides a potential mechanistic link., Highlights • A glutathione S-transferase (GST), Gfzf, decreases mitochondrial fusion in axons • Gfzf loss causes hyperfusion through enhanced oxidation of glutathione • GST loss or enhanced oxidation of glutathione increases the function of mitofusin • Hyperfusion was associated with functional changes but not neurodegeneration, Smith and Lin et al. identify a glutathione S-transferase that decreases mitochondrial fusion in axons of neurons through unbiased genetic screening using Drosophila. gfzf mutants induce sustained hyperfusion through an enhanced oxidation of glutathione that increases the function of mitofusin.

The purpose of this study was to assess Arizona veterinarians’ perceptions and consensus regarding the importance of items in the domains of clinical skills, knowledge, and attributes of Day One graduates of veterinary school and to determine demographic predictors for items on which consensus was low. In this survey-based prospective study, respondents were asked to rate the importance of 44 items on a 5-point Likert scale ranging from 1 ( not at all important) to 5 ( extremely important). Responses were visualized as divergent stacked bar charts and evaluated via summary quantitative and qualitative analyses. Several items had a median score of 5. For clinical skills, items were the ability to formulate a preventive health care plan, the ability to interpret test results, and basic safe handling and restraint of animals; for knowledge, knowledge of pain management and anesthesia; and for attributes, teamwork, problem-solving skills, and client communication skills. The majority of items (80%) had a strong or very strong consensus measure, 18% had a moderate consensus measure, and 2% had a weak consensus measure. Six items (14%) varied by at least one demographic category. We found demographic differences between large and small animal practices in the clinical skill of ability to perform a necropsy, knowledge of large animal theriogenology, and knowledge of canine theriogenology. In conclusion, we found differences in the importance of items and agreement among practitioners, suggesting that critical evaluation of the mapped curriculum, particularly with regard to core curriculum compared with electives and clinical tracks, may benefit students and future employers.

Background Mozambican healthcare workers have high rates of latent and active tuberculosis, but occupational screening for tuberculosis is not routine in this setting. Furthermore, the specificity of tuberculin skin testing in this population compared with interferon gamma release assay testing has not been established. Methods This study was conducted among healthcare workers at Maputo Central Hospital, a public teaching quaternary care hospital in Mozambique. With a cross sectional study design, risk factors for tuberculosis were assessed using multivariable logistic regression. The care cascade is reported for participants who were prescribed six months of isoniazid preventive therapy for HIV or highly reactive testing for latent tuberculosis infection. The agreement of interferon-gamma release assay results with positive tuberculin skin testing was calculated. Results Of 690 screened healthcare workers, three (0.4%) had active tuberculosis and 426 (61.7%) had latent tuberculosis infection. Less education, age 35–49, longer hospital service, and work in the surgery department were associated with increased likelihood of being tuberculosis infected at baseline (p

We describe the first case of a pregnant woman presenting with an acute inverted takotsubo-like cardiomyopathy caused by a postpartum diagnosed hemorrhagic pheochromocytoma, successfully treated with percutaneous venoarterial extracorporeal membrane oxygenation (va-ECMO). During admission, an emergency cesarean delivery had to be performed. The fetus needed resuscitation for 5 minutes. The mother was successfully resuscitated and treated with percutaneous va-ECMO for 7 days. Despite advances in diagnostic techniques during the past decade, in many cases, pheochromocytoma in pregnancy is still missed. This results in a maternal and fetal mortality rate of up to 30% in both.

Rural communities within low-income countries frequently rely on a range of drinking-water sources, and each water source varies in its potential for biological contamination. The extent and source of biological contamination in primary drinking sources within Kien Svay, Kandal, Cambodia, were determined by fecal indicator bacteria (FIB) measurements, 16S rDNA genetic markers for human and bovine fecal Bacteroides, presence of the bloom-forming Microcystis species, and the microcystin toxin mcyD gene marker. Thirteen wells, 11 rain barrels, 10 surface-water sites, and five sediment samples were examined during the dry and wet seasons. Surface water was commonly contaminated with FIB, with up to 1.02 × 105Enterococcus sp., 6.13 × 104E. coli, and 2.91 × 104 total coliforms per 100 mL of water. Human and bovine Bacteroides were detected in 100 and 90% of the surface water samples, respectively. Concentrations of FIB in rain-barrels varied by site, however 91% contained human Bacteroides. Microcystis cells were found in 90% of surface water sites, with many also containing microcystin gene mcyD, representing the first report of microcystin-producing cyanobacteria in surface waters of Cambodia. The study results show that many potential drinking-water sources in Cambodia contain harmful bacterial and algal contaminants, and care should be taken when selecting and monitoring water options.

The SoLid experiment has been designed to search for an oscillation pattern induced by a light sterile neutrino state, utilising the BR2 reactor of SCK$\bullet$CEN, in Belgium. The detector leverages a new hybrid technology, utilising two distinct scintillators in a cubic array, creating a highly segmented detector volume. A combination of 5 cm cubic polyvinyltoluene cells, with $^6$LiF:ZnS(Ag) sheets on two faces of each cube, facilitate reconstruction of the neutrino signals. % The polyvinyltoluene scintillator is used as an $\overline{\nu}_e$ target for the inverse beta decay of ($\overline{\nu}_e + p \rightarrow e^{+}+n$), with the $^6$LiF:ZnS(Ag) sheets used for associated neutron detection. Scintillation signals are read out by a network of wavelength shifting fibres connected to multipixel photon counters. Whilst the high granularity provides a powerful toolset to discriminate backgrounds; by itself the segmentation also represents a challenge in terms of homogeneity and calibration, for a consistent detector response. The search for this light sterile neutrino implies a sensitivity to distortions of around $\mathcal{O}$(10)\% in the energy spectrum of reactor $\overline{\nu}_e$. Hence, a very good neutron detection efficiency, light yield and homogeneous detector response are critical for data validation. The minimal requirements for the SoLid physics program are a light yield and a neutron detection efficiency larger than 40 PA/MeV/cube and 50 \% respectively. In order to guarantee these minimal requirements, the collaboration developed a rigorous quality assurance process for all 12800 cubic cells of the detector. To carry out the quality assurance process, an automated calibration system called CALIPSO was designed and constructed., Comment: Submitted to JINST

BACKGROUND: Understanding the most common and costly conditions treated by inpatient general medical services is important for implementing quality improvement, developing health policy, conducting research, and designing medical education. OBJECTIVE: To determine the prevalence and cost of conditions treated on general internal medicine (GIM) inpatient services. DESIGN: Retrospective cross-sectional study involving 7 hospital sites in Toronto, Canada. PARTICIPANTS: All patients discharged between April 1, 2010 and March 31, 2015 who were admitted to or discharged from an inpatient GIM service. MAIN MEASURES: Hospital administrative data were used to identify diagnoses and costs associated with admissions. The primary discharge diagnosis was identified for each admission and categorized into clinically relevant and mutually exclusive categories using the Clinical Classifications Software (CCS) tool. KEY RESULTS: Among 148,442 admissions, the most common primary discharge diagnoses were heart failure (5.1%), pneumonia (5.0%), urinary tract infection (4.6%), chronic obstructive pulmonary disease (4.5%), and stroke (4.4%). The prevalence of the 20 most common conditions was significantly correlated across hospitals (correlation coefficients ranging from 0.55 to 0.95, p ≤ 0.01 for all comparisons). No single condition represented more than 5.1% of all admissions or more than 7.9% of admissions at any hospital site. The costliest conditions were stroke (median cost $7122, interquartile range 5587–12,354, total cost $94,199,422, representing 6.0% of all costs) and the group of delirium, dementia, and cognitive disorders (median cost $12,831, IQR 9539–17,509, total cost $77,372,541, representing 4.9% of all costs). The 10 most common conditions accounted for only 36.2% of hospitalizations and 36.8% of total costs. The remaining hospitalizations included 223 different CCS conditions. CONCLUSIONS: GIM services care for a markedly heterogeneous population but the most common conditions were similar across 7 hospitals. The diversity of conditions cared for in GIM may be challenging for healthcare delivery and quality improvement. Initiatives that cut across individual diseases to address processes of care, patient experience, and functional outcomes may be more relevant to a greater proportion of the GIM population than disease-specific efforts. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-018-4591-7) contains supplementary material, which is available to authorized users.

This paper presents a comprehensive optimisation study to maximise the light collection efficiency of scintillating cube elements used in the SoLid detector. Very short baseline reactor experiments, like SoLid, look for active to sterile neutrino oscillation signatures in the anti-neutrino energy spectrum as a function of the distance to the core and energy. Performing a precise search requires high light yield of the scintillating elements and uniformity of the response in the detector volume. The SoLid experiment uses an innovative hybrid technology with two different scintillators: polyvinyltoluene scintillator cubes and $^6$LiF:ZnS(Ag) screens. A precision test bench based on a $^{207}$Bi calibration source has been developed to study improvements on the energy resolution and uniformity of the prompt scintillation signal of antineutrino interactions. A trigger system selecting the 1~MeV conversion electrons provides a Gaussian energy peak and allows for precise comparisons of the different detector configurations that were considered to improve the SoLid detector light collection. The light collection efficiency is influenced by the choice of wrapping material, the position of the $^6$LiF:ZnS(Ag) screen, the type of fibre, the number of optical fibres and the type of mirror at the end of the fibre. This study shows that large gains in light collection efficiency are possible compared to the SoLid SM1 prototype. The light yield for the SoLid detector is expected to be at least 52$\pm$2 photo-avalanches per MeV per cube, with a relative non-uniformity of 6 %, demonstrating that the required energy resolution of at least 14 % at 1 MeV can be achieved., 25 pages, 19 figures, published in JINST 2018_JINST_13_P09005

Background Sexually transmitted infections (STIs) increase the risk of HIV transmission and are present at high rates among men who have sex with men (MSM). Adherence to HIV/STI testing guidelines is low in the United States. Testing programs that utilize rapid self-administered HIV/STI tests improve testing rates, though multiple factors influence their uptake. Methods MSM were recruited at an HIV/STI testing and treatment program in 2014 and provided consent, demographics, risk behaviors, HIV/STI test preferences, and perceived testing barriers via an online questionnaire. Comparisons of testing preferences and barriers were made based on age, risk group, and HIV serostatus using the Fisher exact test. Results HIV testing preferences included rapid oral test (71.1%), home test location (78.5%), electronic delivery of HIV-negative test results (76.4%), and direct provider notification for HIV-positive test results (70%), with respondents age >45 years being significantly more likely to prefer home testing (P = .033). STI testing preferences included self-collection of specimens (73.2%), home test location (61%), electronic delivery of negative STI test results (76.4%), and direct provider notification for positive STI test results (56.6%) with no significant differences between age, HIV serostatus, or risk groups. The most frequently reported HIV and STI testing barrier was lack of known prior HIV/STI exposure (57.3% for HIV, 62.9% for STI) with respondents age Conclusions Although additional research is needed, increasing resources directed specifically toward home testing has the potential to translate into improved uptake of rapid HIV/STI testing. Efforts to improve convenience in testing programs must be balanced with the need for continued educational outreach.

Egyptian fruit bats (Rousettus aegyptiacus) were inoculated subcutaneously (n = 22) with Marburg virus (MARV). No deaths, overt signs of morbidity, or gross lesions was identified, but microscopic pathological changes were seen in the liver of infected bats. The virus was detected in 15 different tissues and plasma but only sporadically in mucosal swab samples, urine, and fecal samples. Neither seroconversion nor viremia could be demonstrated in any of the in-contact susceptible bats (n = 14) up to 42 days after exposure to infected bats. In bats rechallenged (n = 4) on day 48 after infection, there was no viremia, and the virus could not be isolated from any of the tissues tested. This study confirmed that infection profiles are consistent with MARV replication in a reservoir host but failed to demonstrate MARV transmission through direct physical contact or indirectly via air. Bats develop strong protective immunity after infection with MARV.

TOPIC A systematic review: Depression and quality of life of adolescents after bariatric surgery. PURPOSE Reported changes in depression and quality of life among adolescents after bariatric surgery were assessed, along with the choice of tools, length of follow-up, and age and gender trends. SOURCES USED Medical and psychosocial electronic databases. CONCLUSIONS The majority of published studies of adolescents post bariatric surgery showed a positive reduction in depression and improvements in quality of life regardless of the amount of weight lost or type of surgery performed. Four studies measured changes only within the first year and three within 2 years; it is unknown if positive psychological benefits persisted. Patients' ages ranged from 9 to 20 years, with an average age of 16.6. A 7:3 female/male ratio presented for surgery. Three depression and six quality of life instruments were utilized; two instruments were validated for adult use only. Consistent qualitative and quantitative measures of psychological issues and quality of life specific to adolescents are necessary. Multicenter longitudinal studies are warranted to more effectively track outcomes and patients needing more support. Thus informed, a nurse or health practitioner can better advocate for the patient during the preoperative, postoperative, and follow-up periods.

Background Tricuspid regurgitation (TR) in patients undergoing surgery for mitral valve (MV) increases morbidity and mortality, especially in case of a poor right ventricle. Does repair of mild-to-moderate insufficiency of the tricuspid valve (TV) in patients undergoing MV surgery lead to a benefit in early postoperative outcome? Methods A total of 22 patients with mild-to-moderate TR underwent MV repair and concomitant TV repair with Tri-Ad (Medtronic ATS Medical Inc., Minneapolis, Minnesota, United States) and Edwards Cosgrove (Edwards Lifesciences Irvine, California, United States) rings. The severity of TR was assessed echocardiographically by using color-Doppler flow images. The tricuspid annular plane systolic excursion (TAPSE) was under 1.7 cm. Additional procedures included coronary artery bypass (n = 9) and maze procedure (n = 15). The following parameters were compared: postoperative and peak dose of noradrenaline (NA), pre/postoperative systolic pulmonary pressure (sPAP), extubation time, operation time, cross-clamp time, cardiopulmonary bypass (CPB) time, pre/postoperative ejection fraction (EF), intensive care unit (ICU)-stay, hospital stay, cell saver blood transfusion, intra/postoperative blood transfusion, and postoperative TR. Results The mean age was 67 ± 14.8 years, 45% were male. Mean EF was 47 ± 16.2%, postoperative 52 ± 12.4%. sPAP was 46 ± 20.1 mm Hg preoperatively, sPAP was 40.6 ± 9.4 mm Hg postoperatively, NA postoperatively was 12 ± 10 μg/min, NA peak was 18 ± 11 μg/min, operation time was 275 ± 92 minutes, CPB was 145 ± 49 minutes, ICU stay was 2.4 ± 2.4 days, hospital stay was 10.8 ± 3.5 days, cell saver blood transfusion was 736 ± 346 mL, intraoperative transfusions were 2.5 ± 1.6. Two patients needed postoperative transfusions. A total of 19 patients were extubated at the 1st postoperative day, 2 patients at the 2nd day, and 1 at the 4th postoperative day. Two patients required a pacemaker. No reintubation, no in-hospital mortality, and one reoperation because of bleeding complications. Conclusion Correction of mild-to-moderate TR at the time of MV repair does maintain TV function and avoid right ventricular dysfunction in the early postoperative period improving the clinical outcome.

Background Tocilizumab (TCZ) is a humanised anti interleukin-6 receptor antibody licensed for use for the treatment of moderate to severe Rheumatoid Arthritis (RA) as monotherapy or in combination with methotrexate (MTX). Objectives To describe the use of TCZ for RA in a large UK teaching centre and examine reasons for treatment discontinuation. Methods A retrospective case note review of all adult patients receiving TCZ either alone or in combination with DMARDS, for the treatment of RA between April 2009 and January 2017 in Sheffield, UK. Results 132 patients received TCZ for RA. 71% were female. 61% were CCP positive. Mean disease duration was 15.6 years (range 1.5–43). 46 (34.6%) received TCZ as monotherapy, 55 (42.1%) in combination with MTX and 31 (23.3%) other DMARDS. 23% of patients received concomitant oral prednisolone. Median duration of TCZ treatment was 27 months across the whole cohort, and 19 months in those who discontinued treatment. Overall 44 (33%) patients discontinued TCZ; 5 due to primary and 10 secondary inefficacy, 27 patients due to adverse events (8 recurrent infection, 5 abnormal LFT, 4 malignancy, 3 rash, 7 other including 1 death whilst on treatment). A logistic regression model, including gender, smoking status, disease duration, DMARD use, steroid treatment and number of prior biologics was constructed to examine association with treatment discontinuation. Of these factors, disease duration (p=0.05) and number of previous biologics (p=0.09) were weakly associated with persistence of TCZ and in particular there was no association of concomitant DMARD or steroid treatment with discontinuation either due to lack of efficacy or adverse events. Table 1 demonstrates the proportion of patients stopping treatment, and treatment duration according to previous biologic treatment received. We have not seen any cases of infusion reaction, diverticular perforation or reactivation of tuberculosis. Conclusions Our real world data on the use of TCZ in the treatment of adult patients with RA is consistent with clinical trial data for efficacy and safety and is similar to other biological drugs used in the treatment of RA. We have seen a relatively low rate of withdrawal due to primary and secondary treatment failure. Disclosure of Interest None declared

Women comprised 19% of new HIV diagnoses in the United States in 2014, with significant racial and ethnic disparities in infection rates. This cross-sectional analysis of women enrolled in a cohort study compares demographics, risk behaviour, and sexually transmitted infections (STI) in those undergoing HIV testing in San Diego County. Data from the most recent screening visit of women undergoing voluntary HIV screening April 2008 –July 2014 was used. HIV diagnosis, risk behaviour and self-reported STIs were compared among women aged ≤24, 25–49, and ≥50, as well as between HIV-infected and uninfected women and between Hispanic and non-Hispanic women. Among the 2535 women included, Hispanic women were less likely than other women to report unprotected vaginal intercourse (p = 0.026) or stimulant drug use (p = 0.026), and more likely to report one or fewer partners (p

Background Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection associated with high dose steroid use in non-HIV patients. Many patients on high dose steroids (>20 mg prednisone equivalents for 28 days or longer), developed PJP within a month of steroid use. This study aims to develop an electronic alert for providers to consider PJP prophylaxis for patients discharged on high-dose steroids. Methods Cases were obtained from the University of Utah Enterprise Data Warehouse between October 2014 and September 2017. A retrospective, manual chart review evaluated adults 18 years of age or older, with an inpatient PJP diagnosis made via direct fluorescent antibody or PCR. Patients with PJP due to HIV were excluded. Steroid dose and duration one month prior to diagnosis of PJP were evaluated. After retrospective analysis, via a multidisciplinary team, a best practice advisory (BPA) alert was created to flag providers to consider PJP prophylaxis at discharge, with consideration of creatinine levels and allergy profile to guide drug choices. The alert was trailed in a silent mode from January to April 2018 without provider notification so it could be modified to prevent inappropriate firing. The alert was approved for live use by the Clinical Decision Support Committee and is now active in the University of Utah Epic system as of April 10, 2018. Results In retrospective analysis, of 94 non-HIV patients diagnosed with PJP, 31/94 (33%) cases were in the setting of high dose steroids. 7/31 (23%) cases were exclusively with high dose steroids, while 24/31 (77%) cases were in combination with chemotherapy or other immune modulating agents. Data from the silent BPA from February to April 2018 demonstrated 23 cases triggered the alert, all of which were determined to be appropriate by chart review. Since live use, the BPA has fired 15 times, of which 14 cases met criteria for prophylaxis and 4/14 (29%) resulted in prophylaxis on discharge. Conclusion Chart review identified high dose steroids as a target for a quality improvement intervention, which led to development of a BPA. Data indicates room for improvement on discharge with prophylaxis. Goals include reducing morbidity, mortality and cost associated with PJP, as well as educating providers regarding the need for prophylaxis. Disclosures All authors: No reported disclosures.

Background Many families arrive at the United States–Mexico border seeking asylum. Jewish Family Service and the San Diego Rapid Response Network operate a shelter in San Diego that provides shelter, food, clothing, legal services and travel coordination for asylum-seeking families. Two local federally qualified health centers provide on-site urgent care. Methods In late December 2018, the County of San Diego expanded public health efforts by conducting health screenings of guests upon entry to the shelter with the goal of identifying health issues requiring urgent or emergent evaluation and preventing the spread of communicable disease. University of California San Diego Health physicians contracted by the County of San Diego Health and Human Services Agency (HHSA) nurses and ancillary staff provide daily on-site services to all shelter entrants including: health screening for diseases of public health significance, treatment and/or referral of urgent conditions, and medical clearance for shelter entry or medical isolation as needed. Official tracking of screening outcomes from January 2 to April 24, 2019 were collected using standardized surveys and analyzed for program evaluation and surveillance purposes. Results During that time a total of 9,124 asylum-seekers were screened, averaging 81 guests daily, identifying: 42 influenza-like illness, 645 lice, 330 scabies, 8 varicella, and 0 hepatitis A cases. Chest radiography for suspected tuberculosis was performed for 29 guests. Only one chest x-ray was abnormal. Sputum specimens for acid-fast stain (n = 3) and nucleic acid testing (n = 2) were all negative and no tuberculosis cases were diagnosed. Emergency department referrals were made for Conclusion Coordination among local partner agencies resulted in early identification of communicable and acute health conditions prior to shelter entry allowing evaluation, treatment and off-site isolation, and minimizing stress on the emergency medical services system. This approach provides a successful model for health screening of asylum-seeking families arriving at the United States–Mexico border. Disclosures All authors: No reported disclosures.