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This study addresses rural Guatemala's poor maternal health and HIV status by culturally adapting an evidence-based HIV intervention, SEPA (Self-Care, Education, Prevention, Self-Care), to extend the capacity of comadronas (Mayan birth attendants) as HIV prevention providers. This mixed-method study examined the acceptability, suitability, and feasibility of SEPA presented to traditional elder and a younger cohort of comadronas over three sessions. Outcome variables were reported as mean scores. Open-ended qualitative responses were categorized under central themes. Session 1, 2, and 3 acceptability (4.6/5, 4.6/5, 4.8/5), suitability (4.7/5, 4.6/5, 4.9/5), and feasibility (4.4/5, 4.7/5, 4.8/5) remained high across sessions. While comadronas reported that information was difficult, they reported high levels of understanding and comfort with SEPA content and they also found it to be culturally appropriate, increasing their confidence to discuss HIV with their community. The broader utilization of comadronas could create a pathway to enhance reproductive health among indigenous women.

Background Miami, FL is the epicenter of the HIV epidemic in the US, with 20% of new HIV infections occurring in women. Despite the effectiveness of PrEP, only 10% of eligible women benefit from its use. This study evaluates PrEP awareness and use, and factors associated with PrEP awareness among reproductive age sexually active women in Miami. Methods From 2018 to 2022, cis-gender, HIV-negative, 18-45-year-old, sexually active women were recruited as part of a study evaluating HIV risk. Participants completed questionnaires assessing socio-demographics, HIV risk behaviors, prior HIV testing, PrEP awareness and use, and were tested for STIs (chlamydia, gonorrhea, trichomoniasis) and bacterial vaginosis (BV). Factors associated with PrEP awareness were analyzed by Chi-square, Fisher’s exact test, or studentized t-test. Multivariable logistic regression (MLR) was performed to identify factors associated with PrEP awareness. Results 295 women were enrolled; median age 31 (24-38) years, 49% Black, 39% White, 34% Hispanic, 46% income below poverty line, 24% consistent condom use, 1.6 (±2.57) mean number of partners in the previous month, 80% heterosexual, 73% previously tested for HIV, 22% STI, and 50% BV. Of the 63% who knew about PrEP, only 5% were on PrEP. Women aware of PrEP were more likely to be Black, non-Hispanic, have income below poverty line, non-heterosexual, report prior HIV testing, and have a STI or BV (all p< 0.05). Condom use and number of partners were not associated with PrEP awareness. In MLR, women with income below poverty line (OR=2.00 [1.04,3.87]; p=0.04), more sexual partners (OR=1.30 [1.01,1.68]; p=0.04), prior HIV testing (OR=6.42 [2.83,14.52]; p< 0.01), and BV (OR=2.28 [1.18,4.40]; p=0.01) were more likely to be aware of PrEP. Lower odds of PrEP awareness were associated with being Black (OR=0.38 [0.15,0.96]; p=0.04), Hispanic (OR=0.18 [0.08,0.39]; p< 0.01), Heterosexual (OR=0.29 [0.11,0.77]; p< 0.01), and reporting occasional condom use (OR=0.21 [0.08,0.56]; p< 0.01). Conclusion Despite broad PrEP awareness, PrEP use is alarming low among those women at greatest risk. HIV testing presents an opportunity to increase PrEP awareness, but interventions to increase PrEP uptake are needed to end the HIV epidemic among women. Disclosures Maria L L. Alcaide, MD, Gilead: Advisor/Consultant.

Background Human papillomavirus (HPV) is the most common STI in the US, responsible for cervical cancer and increased risk of HIV acquisition. Despite an effective HPV vaccine, women’s HPV vaccination coverage and rates remain far below desired levels. This study aimed to evaluate HPV knowledge, screening, and vaccination practices as well as factors associated with HPV vaccination among women of reproductive age living in Miami, Florida, a Southern US city with a high incidence of STIs and low HPV vaccination coverage. Methods In April 2022, HIV-negative, cisgender, sexually active women aged 18-45 years were referred from a study evaluating HIV risks. Surveys assessed socio-demographics and sexual behaviors. Validated questionnaires assessed HPV knowledge, screening, and vaccination practices. A cumulative HPV knowledge score was generated. Factors associated with HPV vaccination were analyzed by Chi-square, Fisher’s exact test, studentized t-test, and multivariate logistic regression (MLR). Results A total of 67 participants were enrolled, and 54 who knew their vaccination status were included in the analysis: median age was 26 (IQR 22-34.5) years; 50% were White, 26% Black, and 33% were Hispanic. Median age at first sexual encounter was 18 (16-18) years, the mean number of sexual partners in the previous month was 1.45 (±1.44), and 33% had previous pregnancies. Mean HPV score was 13.4 (±8.84) out of 29, 43% reported a history of HPV/Pap smear screening. Barriers to HPV vaccination included: 28% low-risk perception, 24% healthcare barriers, and 41% vaccine hesitancy. In MLR, a one-point increase in HPV knowledge score increased the odds of vaccination by 21.5% (0.8-3.67%; p< 0.01). Age, number of sexual partners, and pregnancy history were not significant predictors of HPV vaccination. Conclusion Findings suggest low HPV knowledge among women of reproductive age in a high-risk area, and suggest that increasing knowledge may reduce barriers to HPV vaccination and increase vaccine uptake. Disclosures Maria L L. Alcaide, MD, Gilead: Advisor/Consultant.

Background Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the US, responsible for cervical cancer and increased risk of Human Immunodeficiency Virus (HIV) acquisition. Despite an effective HPV vaccine, women’s HPV vaccination coverage and rates remain far below desired levels. This study aimed to evaluate HPV knowledge, attitudes, and vaccination practices as well as factors associated with HPV vaccination among women of reproductive age living in Miami, Florida, a Southern US city with a high incidence of STIs and low HPV vaccination coverage. Methods From April to June 2022, 100 HIV-negative, cisgender, sexually active women aged 18–45 years were recruited from the Miami community. Participants completed validated questionnaires using REDCap© electronic surveys, assessing socio-demographics and sexual behaviors; HPV knowledge, screening, vaccination practices; barriers and motivators to HPV vaccination. A cumulative HPV knowledge score (HPV score) was generated. Factors associated with HPV vaccination were analyzed by Chi-square, Fisher’s exact test, studentized t-test, and multivariate logistic regression (MLR). Results A total of 100 participants were enrolled, and 84 who knew their vaccination status were included in the analysis. Of these, 43 reported receiving at least 1 HPV vaccine dose (vaccinated group) and 41 reported never being vaccinated (unvaccinated group). Mean age was 24.7 (SD 4.03) years for the vaccinated group and 31.4 (SD 8.33) for the unvaccinated group. Mean HPV score was 18.9/29 (SD 6.05) for the vaccinated group and 9.1/29 (SD 8.82) for the unvaccinated group. Amongst vaccinated participants, 76.74% reported a history of HPV/Pap smear screening vs 87.80% in the unvaccinated group. Barriers to HPV vaccination included: 14.6% low-risk perception, 29.3% healthcare barriers, and 46.3% vaccine hesitancy and personal beliefs. Motivators t HPV vaccination included: risk perception and vaccine beliefs (71.42%), healthcare-related (60.71%) and social motivators (55.95%). In the first MLR, one-point increases in HPV score were significantly associated with higher odds of HPV vaccination until an HPV score of 16, and a one-year increase in age was associated with a 16% lower odds of HPV vaccination (aOR = 0.84, 95% CI [0.72, 0.99]; p = 0.035). Contraception use was also associated with HPV vaccination (aOR 8.36 (95% CI [1.41, 49.62]; p = 0.020). Race, ethnicity, college education status, and number of sexual partners were not significant predictors of HPV vaccination. In the second MLR evaluating vaccination motivators as predictors of HPV vaccination, we found that individuals who were motivated by healthcare had 3.03 (95% CI [1.02, 9.00]; p = 0.046) times the odds of HPV vaccination compared to individuals without healthcare-related motivators. Conclusion Findings suggest suboptimal HPV knowledge and low vaccination rates among women of reproductive age. Public health efforts should focus on increasing basic HPV knowledge among women with little-to-no HPV knowledge to increase vaccine uptake.

PURPOSE: A dense breast on mammogram is a strong risk factor for breast cancer. Identifying factors that reduce mammographic breast density could thus provide insight into breast cancer prevention. Due to the limited number of studies and conflicting findings, we investigated the associations of medication use (specifically statins, aspirin, and ibuprofen) with mammographic breast density. METHODS: We evaluated these associations in 775 women who were recruited during an annual screening mammogram at Washington University School of Medicine, St. Louis. We measured mammographic breast density using Volpara. We used multivariable-adjusted linear regressions to determine the associations of medication use (statins, aspirin, and ibuprofen) with mammographic breast density. Least squared means were generated and back-transformed for easier interpretation. RESULTS: The mean age of study participants was 52.9 years. Statin use in the prior 12 months was not associated with volumetric percent density or dense volume, but was positively associated with non-dense volume. The mean volumetric percent density was 8.6% among statin non-users, 7.2% among women who used statins 1–3 days/week, and 7.3% among women who used statins ≥4 days/week (p-trend=0.07). The non-dense volume was 1297.1cm(3) among statin non-users, 1368.7cm(3) among women who used statins 1–3 days/week, and 1408.4cm(3) among those who used statins ≥4 days/week (p-trend=0.02). We did not observe statistically significant differences in mammographic breast density by aspirin or ibuprofen use. CONCLUSION: Statin, aspirin, and ibuprofen use was not associated with volumetric percent density and dense volume, but statin use was positively associated with non-dense volume. Any potential associations of these medications with breast cancer risk are unlikely to be mediated through an effect on volumetric percent density.

We evaluated the psychometric properties of a modified version of the Vaccine Hesitancy Scale (VHS) among people with HIV (PWH) for COVID-19 vaccination in a cross-sectional study in the US. Self-report data from an online questionnaire were collected from a sample of N = 175 PWH. Participants were surveyed in English or Spanish regarding attitudes towards COVID-19 vaccination using the adapted VHS. Participants were on average 51.55 years of age (SD = 13.90) 55% were women. The reliability of the scale was acceptable (α = 0.72). An exploratory factor analysis showed that "Lack of confidence" and "Risks" explained 45.55% and 12.31% of the variance. Related items showed expected associations with these factors, supporting construct validity. Results illustrate that the modified VHS for COVID-19 vaccination has adequate psychometric properties. We replicated the original factor structure of the VHS and demonstrated adequate internal consistency and construct validity. Validated tools are essential to guide vaccination policy and campaigns towards populations at risk.En este estudio transversal, evaluamos las propiedades psicométricas de la Escala de Reticencia a la Vacunación (VHS, por sus siglas en inglés) para la vacuna contra el COVID-19 en personas con VIH (PCV) en los EE. UU. Los participantes (N = 175) respondieron a una encuesta en línea en inglés o en español, sobre las actitudes hacia la vacuna contra el COVID-19 utilizando una version adaptada de la VHS. La edad promedio de los participantes fue de 51,55 años (DE = 13,90;) y 55% eran mujeres. La fiabilidad de la escala fue aceptable (α = 0,72). Un análisis factorial exploratorio mostró que la “falta de confianza” y los “riesgos” explicaron el 45,55% y el 12,31% de la varianza. Los elementos relacionados mostraron asociaciones esperadas con dichos factores, apoyando la validez de la VHS adaptada para esta población. Los resultados ilustran que la VHS modificada para la vacuna contra el COVID-19 tiene propiedades psicométricas adecuadas. Replicamos la estructura factorial original de la VHS y demostramos una adecuada validez y consistencia interna. La validación de instrumentos de recolección de datos es esencial para orientar las políticas y campañas de vacunación para poblaciones en riesgo, tal como PCV.

Bacterial vaginosis (BV) is the most common genital infection in women and is associated with an increased risk of sexually transmitted infections and HIV. This study uses a syndemic approach to evaluate factors associated with BV. Non-pregnant, HIV-negative, sexually active, cis-gender women aged 18-45 years living in Miami, Florida were recruited from Nov.2018- Jun.2021. Participants completed a sociodemographic and behavioral questionnaire along with gynecological examinations. BV was diagnosed by Amsel criteria and confirmed by a Nugent score ≥ 4. A syndemic score was calculated as the sum of factors associated with BV. The association between syndemic score and BV was assessed using logistic regression. Of 166 women included, 60.2% had BV. Race, ethnicity, education, vaginal sex, recent cannabis use, and reasons for intravaginal practices were included in the syndemic score. Higher odds of BV were found in women with a score of ≥ 3 compared to women with a score of 0/1. A higher syndemic score was associated with increased odds of having BV. Multilevel interventions to decrease BV are needed to decrease women's risk of acquiring HIV.La vaginosis bacteriana (VB) es la infección genital más común en mujeres y está asociada con un mayor riesgo de enfermedades de transmisión sexual (ETS) y de VIH. Este estudio utilizó un enfoque sindémico para evaluar factores asociados con VB. Entre noviembre del 2018 y junio del 2021, se reclutaron mujeres cisgénero de entre 18–45 años, que no estuvieran embarazadas, que fueran VIH negativas y sexualmente activas, y que vivieran en Miami, Florida. Las participantes completaron un cuestionario sociodemográfico y de comportamiento junto con un examen ginecológico. Se diagnosticó VB empleando los criterios de Amsel y se confirmó empleando el criterio de Nugent con una puntuación ≥ 4. La puntuación sindémica fue calculada como la suma de factores asociados con VB utilizando. La asociación entre la puntuación sindémica con VB se evaluó mediate una regresión logística. De 166 mujeres incluidas, 60.2% fueron diagnosticadas con VB. Los factores incluidos en la puntuación sindémica fueron la raza, etnia, educación, sexo vaginal, consumo reciente de cannabis, y el uso de prácticas intravaginales. Se encontraron mayores probabilidades de VB en mujeres con una puntuación ≥ 3 en comparación con aquellas con una puntuación de 0/1. Una puntuación sindémica alta se asoció con una mayor probabilidad de tener VB. Son necesarias intervenciones multinivel para disminuir la VB y disminuir el riesgo de que las mujeres contraigan ETS y VIH.

Background: Mammographic breast density (MBD) is a strong modifiable risk factor for breast cancer, especially in premenopausal women. It is estimated that up to 39% of breast cancer cases in premenopausal women could potentially be prevented by reducing dense breasts to non-dense breasts. Therefore, reducing breast density through targeted interventions is an excellent opportunity to substantially reduce breast cancer incidence in premenopausal women. We performed a critical evaluation of the literature to determine the associations of chemoprevention agents use with MBD. This will guide the management of premenopausal women at risk for breast cancer. Methods: Eleven databases were searched on July 2019. We included interventional, cross-sectional, longitudinal or observational studies in Englishreporting the associations of medication with mammographic breast density in premenopausal womenwith no history of breast cancer. Two researchers extracted the data and assessed the quality of the studies. Supplements not otherwise specified were excluded. Results: After de-duplication process, 1,464 citations were screened for eligibility. Seven studies met our inclusion criteria: two observational, four randomized controlled, and one non-randomized controlled trials (RCT). There were two categories of medications: dietary supplements (i.e. vitamin D, calcium, isoflavone) and drugs (non-steroidal anti-inflammatory drugs [NSAIDs], selective estrogen receptor modulators (SERMs) goserelin, and GnRHA deslorelin acetate). In observational studies, calcium use was associated with a significant reduction in MBD, while vitamin D and NSAIDs showed no reduction6. Likewise, Isoflavone and vitamin D in doses of 1000, 2000 or 3,000IU/day were not associated with a reduction in MBD in two different RCT. Groselin, GnRHA, deslorein acetate, statins were not associated with MBD reduction in an RCT’s. SERMs (tamoxifene and raloxifene) were the only drugs associated with reductions in MBD in RCTs. Conclusions: Only a very limited number of medications (SERMs) are associated with reductions in MBD. In view of their low uptake and adherence, identifying other medications that can reduce MBD is crucial, as these could have utility in breast cancer prevention. Citation Format: Ana S. Salazar, Malika Rakhmankulova, Laura E. Simmon, Adetunji Toriola. Medication use to reduce mammographic breast density in premenopausal women: A systematic review [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-08-71.

Summary Background Candida bloodstream infection is associated with high mortality. Infectious disease consultation improves outcomes in several infections, including Staphylococcus aureus and cryptococcosis, as well as multidrug-resistant organisms. We aimed to examine the association between infectious disease consultation and differences in management with mortality in candida bloodstream infections. Methods In this retrospective, single-centre cohort study, we reviewed the medical charts of all patients admitted to Barnes-Jewish Hospital (St Louis, MO, USA), a tertiary referral centre, aged 18 years or older with candida bloodstream infection from 2002 to 2015. We collected data for demographics, comorbidities, predisposing factors, all-cause mortality, antifungal use, central-line removal, and ophthalmological and echocardiographic evaluation to assess 90-day all-cause mortality between individuals with and without an infectious disease consultation. For the survival analysis we used Cox proportional hazards model with inverse weighting by propensity score to assess the effects of infectious disease consultation on mortality and differences in management. Findings Between Jan 1, 2002, and Dec 31, 2015, of 1794 patients assessed for eligibility, we analysed 1691 patients with candida bloodstream infection; 776 (45·9%) who had an infectious disease consultation and 915 (54·1%) who did not have an infectious disease consultation. All 1691 patients were included in the analysis. None were missing data. Most underlying comorbidities were evenly distributed between groups. 90-day mortality was lower in the infectious disease consultation group than in patients who did not receive an infectious disease consultation (29% [222/776] vs 51% [468/915]; p Interpretation Patients with candida bloodstream infection receiving an infectious disease consultation have lower mortality. This finding might be attributable to these individuals receiving a higher number of non-pharmacological, evidence-based interventions and lower amounts of non-treatment. These data suggest that an infectious disease consultation should be an integral part of clinical care of patients with candida bloodstream infection. Funding Astellas Global Development Pharma, Washington University Institute of Clinical and Translational Sciences, and the Agency for Healthcare Research and Quality.

BACKGROUND: Candidemia is the most common clinical presentation of invasive candidiasis and is a major cause of morbidity and mortality. Candiduria is a predictor for candidemia; however, patient characteristics that are associated with concurrent candidemia in the setting of candiduria are unclear. Identifying these characteristics could aid in the early detection of systemic disease. METHODS: We performed a retrospective cohort analysis of hospitalized patients with candiduria at our institution over a 13-year period. Our evaluation of patient characteristics included demographics, comorbidities, medications, procedures, devices, vital signs, and laboratory values. We developed a multivariable logistic model to identify factors associated with candidemia in patients with candiduria. RESULTS: We identified 4,240 patients with candiduria, 263 (6.2%) of whom had candidemia. Predictors for increased risk of candidemia with candiduria included hospitalizations greater than 12 days, central venous catheter, parenteral nutrition, hematological and gynecological malignancy, and receipt of β-lactam/β-lactamase inhibitors. Vital signs and laboratory values associated with candidemia included elevated heart rate, temperature, and creatinine, along with neutropenia and neutrophilia. Factors that demonstrated a decreased risk of candidemia included diabetes mellitus, gastrostomy, and urinary catheter with antibiotic use. The c-statistic was 0.741 (95% CI, 0.710 – 0.772). CONCLUSION: We identified a set of clinical characteristics that can predict the presence of candidemia with candiduria.

BackgroundThe concentration and duration of antibodies (Ab) to SARS-CoV-2 infection predicts the severity of the disease and the clinical outcomes. Older people and those with HIV have impaired immune responses, worse outcomes after SARS-CoV-2 infection, and lower antibody responses after viral infection and vaccination. This study evaluated an Ab response to SARS-CoV-2 in people with HIV (PWH) and without HIV (HIV-) and its association with age.MethodsA total of 23 COVID+PWH and 21 COVID+HIV- participants were followed longitudinally for 6 months post-mild COVID-19. Immunoglobin G (IgG) and immunoglobin M (IgM) Ab responses were measured by an in-house developed ELISA. Time points and HIV status interaction were analyzed using Poisson generalized estimating equations, and correlations were analyzed using non-parametric tests.ResultsMedian age in PWH was 55 years with 28.6% women, while in the HIV- group was 36 years with 60.9% women. The mean time from COVID-19 diagnosis to study enrollment was 16 days for PWH and 11 days for HIV-. The mean CD4+ T-cell count/μl for PWH was 772.10 (±365.21). SARS-CoV-2 IgM and IgG were detected at all time points and Ab response levels did not differ by HIV status (p > 0.05). At entry, age showed a weak direct association with IgG responses (ρ = 0.44, p < 0.05) in HIV- but did not show any association in PWH. Similar associations between age, IgG, and HIV status emerged at day 14 (T1; ρ = 0.50, p < 0.05), 3 months (T3; ρ = 0.50, p < 0.05), and 6 months visit (T4; ρ = 0.78, p < 0.05) in the HIV- group.ConclusionThe Ab responses in the 6-month post-SARS-CoV-2 infection did not differ by HIV status, though a positive association was found between age and Ab response in older PWH. Results suggest that immune protection and vaccine responses are similar for PWH than for those without HIV infection.

Higher mammographic breast density (MBD) is associated with an increased risk of breast cancer when compared with lower MBD, especially in premenopausal women. However, little is known about the effectiveness of chemoprevention agents in reducing MBD in premenopausal women without a history of breast cancer. Findings from this review should provide insight on how to target MBD in breast cancer prevention in premenopausal women with dense breasts.We searched 9 electronic databases for clinical trials in English, Spanish, French, or German published until January 2020. Articles evaluating the association of pharmacological agents and MBD were included. Data were extracted on methods, type and dose of intervention, outcomes, side effects, and follow up. Quality of the studies was assessed using the US Preventive Services Task Force criteria.We identified 7 clinical trials evaluating the associations of 6 chemoprevention agents with changes in MBD in premenopausal women without history of breast cancer. The studies evaluated selective estrogen-receptor modulators (n = 1); gonadotropin-releasing hormone agonists (n = 2); isoflavones (n = 1); vitamin D (n = 1); and Boswellia, betaine, and mayo-inositol compound (n = 1). Hormonal interventions were associated with net reductions in percent density (tamoxifen [13.4%], leuprolide acetate [8.9%], and goserelin [2.7%]), whereas nonhormonal (vitamin D and isoflavone) interventions were not. However, MBD returned to preintervention baseline levels after cessation of gonadotropin-releasing hormone agonists.A limited number of chemoprevention agents have been shown to reduce MBD in premenopausal women. Identification of new and well-tolerated chemoprevention agents targeting MBD and larger studies to confirm agents that have been studied in small trials are urgent priorities for primary breast cancer prevention in premenopausal women with dense breasts.

Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and human immunodeficiency virus (HIV) disproportionally affect underrepresented ethnoracial groups in the United States. Medical mistrust and vaccine hesitancy will likely impact acceptability of SARS-CoV-2 vaccines. This study examined SARS-CoV-2 vaccine hesitancy among underrepresented ethnoracial groups with HIV and identified factors that may reduce vaccine uptake. Methods We conducted a cross-sectional study of adults ≥18 years of age with HIV residing in Miami, Florida. Participants were invited to participate in the ACTION (A Comprehensive Translational Initiative on Novel Coronavirus) cohort study. A baseline survey was administered from April to August 2020 and followed by a coronavirus disease 2019 (COVID-19) vaccine hesitancy survey from August to November 2020. The COVID-19 vaccine hesitancy survey was adapted from the Strategic Advisory Group of Experts survey. Comparisons by race and ethnicity were performed using the Freedman-Haltmann extension of the Fisher exact test. Results A total of 94 participants were enrolled; mean age was 54.4 years, 52% were female, 60% were Black non-Latinx, and 40% were non-Black Latinx. Black non-Latinx participants were less likely to agree that vaccinations are important for health when compared to non-Black Latinx (67.8% vs 92.1%, P = .009), less likely to agree that vaccines are effective in preventing disease (67.8% vs 84.2%, P = .029), less likely to believe that vaccine information is reliable and trustworthy (35.7% vs 71.1%, P = .002), and less likely to believe vaccines were unnecessary because COVID-19 would disappear soon (11% vs 21%, P = .049). Conclusions Medical mistrust, vaccine hesitancy, and negative sentiments about SARS-CoV-2 vaccines are prevalent among underrepresented ethnoracial groups with HIV, particularly Black non-Latinx. Targeted strategies to increase vaccine uptake in this population are warranted.

Little is known about the psychological implications of the coronavirus disease 2019 (COVID-19) pandemic on people with HIV. The purpose of this study was to assess the impact of COVID-19 among men and women with HIV in Miami, Florida. We hypothesized that the burden of the COVID-19 pandemic will be higher for women, and psychological factors will increase COVID-19 burden among them. People with (n = 231) and without HIV (n = 42) residing in Miami, Florida completed a survey assessing psychological outcomes such as loneliness, depression, and stress, as well as the burden of COVID-19, on their daily lives. t-Tests and chi-square analyses were used to assess sex differences in study variables. Logistic regression was used to compare the interaction effects predicting stress and loneliness by COVID-19 burden and sex. A total of 273 completed the survey; the outcomes of the study, loneliness, and stress did not differ by HIV status (p = .458 and p = .922). Overall, men and women reported similar prevalence of COVID-19 burden. However, a greater proportion of women reported losing childcare than men (18% vs. 9%, p = .029, respectively), as well as losing mental health care (15% vs. 7%, p = .049, respectively). There was a significant interaction between COVID-19 burden and sex for loneliness and stress such that the association between COVID-19 burden and loneliness was greater for women (p < .001) than for men (p = .353) and the association between COVID-19 burden and stress was greater for women (p = .013) than men (p = .628). Both men and women with HIV are impacted by the COVID-19 pandemic, but women may experience higher levels of stress and loneliness than men. Sex differences may require tailored interventions to more effectively mitigate the impact of the pandemic on mental health.

The COVID-19 pandemic poses a risk to mental health and may disproportionately affect people living with HIV (PLWH). This study examined the interaction of social support and resilient coping in predicting depressive symptoms among PLWH. PLWH residing in Buenos Aires, Argentina and in Miami, Florida (US) were asked to complete an anonymous survey on the impact of COVID-19. Statistical analysis included ordinary least squares regression. A total of 1,554 participants were included. Mean age was 47.30 years; 63.70% were men. A test of three-way interaction of social support × resilient coping × study site indicated differences by site (b = -0.63, p = 0.04, 95%CI [-1.24, -0.02]). In Argentina, higher levels of social support and resilient coping were associated with lower depressive symptoms. Lower levels of social support and resilient coping were associated with higher depressive symptoms. The impact of COVID-19 on mental health illustrates the need for developing innovative strategies to support resilience and to enhance coping with stress and adversity among PLWH.La pandemia de COVID-19 presenta riesgos importantes para la salud mental y puede afectar desproporcionadamente a personas con VIH. Este estudio examinó el efecto entre el apoyo social y la resiliencia para afrontar situaciones difíciles en predecir síntomas depresivos en personas con VIH. Personas con VIH residentes de Buenos Aires (Argentina) y Miami, Florida (EE.UU) completaron una encuesta anónima sobre el impacto del COVID-19. El análisis estadístico incluyó un modelo clásico de regresión lineal con mínimos cuadrados ordinarios. Se incluyeron 1554 participantes. La edad promedio fue 47.30 años y 63.7% eran hombres. La prueba de interacción de apoyo social × resiliencia para hacer frente a situaciones difíciles × país indicó diferencias entre países (b = −0.63, p = 0.043, IC 95% [1.24, −0.02]). En Argentina, los participantes con mayor apoyo social y resiliencia para hacer frente a situaciones difíciles mostraron síntomas depresivos más bajos; y aquellos con menor apoyo social y resiliencia para hacer frente a situaciones difíciles, mostraron síntomas depresivos más altos. Este efecto no se observó en los participantes de Miami. El impacto de COVID-19 en la salud mental en personas con VIH ilustra la necesidad de desarrollar estrategias innovadoras para apoyar la resiliencia y mejorar el enfrentamiento del estrés y la adversidad.

BackgroundHigher mammographic breast density (MBD) is associated with an increased risk of breast cancer when compared with lower MBD, especially in premenopausal women. However, little is known about the effectiveness of chemoprevention agents in reducing MBD in premenopausal women without a history of breast cancer. Findings from this review should provide insight on how to target MBD in breast cancer prevention in premenopausal women with dense breasts.MethodsWe searched 9 electronic databases for clinical trials in English, Spanish, French, or German published until January 2020. Articles evaluating the association of pharmacological agents and MBD were included. Data were extracted on methods, type and dose of intervention, outcomes, side effects, and follow up. Quality of the studies was assessed using the US Preventive Services Task Force criteria.ResultsWe identified 7 clinical trials evaluating the associations of 6 chemoprevention agents with changes in MBD in premenopausal women without history of breast cancer. The studies evaluated selective estrogen-receptor modulators (n = 1); gonadotropin-releasing hormone agonists (n = 2); isoflavones (n = 1); vitamin D (n = 1); and Boswellia, betaine, and mayo-inositol compound (n = 1). Hormonal interventions were associated with net reductions in percent density (tamoxifen [13.4%], leuprolide acetate [8.9%], and goserelin [2.7%]), whereas nonhormonal (vitamin D and isoflavone) interventions were not. However, MBD returned to preintervention baseline levels after cessation of gonadotropin-releasing hormone agonists.ConclusionsA limited number of chemoprevention agents have been shown to reduce MBD in premenopausal women. Identification of new and well-tolerated chemoprevention agents targeting MBD and larger studies to confirm agents that have been studied in small trials are urgent priorities for primary breast cancer prevention in premenopausal women with dense breasts.

Background As the COronaVIrus Disease 2019 (COVID-19) continues to unfold, drastic changes in daily life pose significant challenges on mental and clinical health. While public health interventions such as national lockdowns and social distancing are enforced to reduce the spread of COVID-19, the psychosocial and physical consequences have yet to be determined that may disproportionately affect people living with HIV (PLWH). Methods To evaluate the impact of COVID-related stress on mental and clinical health, we conducted a 20-minute questionnaire eliciting sociodemographic information, clinical and psychological factors from people living in Miami, Fl. All individuals >18 years with or without a history of COVID-19 were included. Participating PLWH were recruited from an existing HIV registry and HIV uninfected participants from community flyers and word of mouth. Results A total of 135 participants were recruited from 05/2020-06/2020. The mean age was 50 years old, 73/135 (54%) were female, and 102/135 (75%) were PLWH. Among participating PLWH, 60/102 (58.8%) self-identified as African American, and 9/102 (8.8%) were positive for COVID-19 by a commercially approved test. Among HIV-negative participants, 15/33 (45.5%) self-identified as White and 11/33 (33%) were positive for COVID-19. Both PLWH and HIV-negative participants described significant disruptions in health care access (47%), difficulty paying basic needs (41%), and feelings of anxiety and depression (48%); there was no statistically significant difference by HIV status. However, HIV negative participants were less likely to experience job loss and income disruption compared to PLWH during the pandemic (70% for HIV-negative vs 48% for PLWH; OR 0.40, p=0.03). Conclusion The impact of COVID-19 on emotional and clinical health is significant in both PLWH and HIV-negative groups. These findings highlight the need for providing mental and physical health care during the pandemic, especially for coping with stress and anxiety during these difficult times and ensuring adequate access to health care. Disclosures All Authors: No reported disclosures

Background Cryptococcosis is one of the most common life-threatening opportunistic mycoses worldwide. Insidious presentation and slow onset of symptoms make it difficult to recognize, complicating the diagnostic process. Delays in diagnosis may lead to increased mortality. We aim to determine the frequency of missed opportunities for diagnosis of cryptococcosis and its effects on mortality. Methods To estimate the proportion of individuals with a potentially missed diagnosis for cryptococcosis in hospitalized patients, we conducted a retrospective cohort study using the Healthcare Cost and Utilization Project State Inpatient Databases from 2005 to 2015 from eight states. All hospitalized adult patients diagnosed with cryptococcal infection or cryptococcal meningitis were included. Potentially missed diagnoses were defined as admissions coded for a procedure or diagnosis suggestive of cryptococcosis in the 90-days prior to the initial cryptococcosis admission. Generalized estimating equations models were used to evaluate the association between underlying comorbidities and potential missed diagnosis of cryptococcosis and 90-day all-cause in-hospital mortality. Findings Of 5,354 patients with cryptococcosis, 2,445 (45·7%) were people living with HIV (PLWH). Among PLWH, 493/2,445 (20·2%) had a potentially missed diagnosis, of which 83/493 (16·8%) died while hospitalized compared with 265/1,952 (13·6%) of those without a potentially missed diagnosis (relative risk [RR] 1·04, 95% CI 0·99–1·09). Among HIV-negative patients, 977/2,909 (33·6%) had a potentially missed diagnosis, of which 236/977 (24·2%) died while hospitalized compared with 298/1,932 (15·4%) of those not missed (RR 1·12, 95% CI 1·07–1·16). Interpretation Missed opportunities to diagnose cryptococcosis are common despite highly efficacious diagnostic tests and are associated with increased risk of 90-day mortality in HIV-negative patients. A high index of clinical suspicion is paramount to promptly diagnose, treat, and improve cryptococcosis-related mortality. Funding National Center for Advancing Translational Sciences, Washington University Institute of Clinical and Translational Sciences, and the Agency for Healthcare Research and Quality.

Lung cancer screening with low-dose computed tomography (LDCT) reduces lung cancer mortality, yet few eligible high-risk patients receive it annually. This protocol describes a community-partnered intervention (Toolkit) designed to support primary care practices in making referrals for lung screening and guiding patients into appropriate screening pathways. This study uses a stepped-wedge implementation design. Screening centers are randomized by readiness level to enter the intervention phase in three-month "steps" with pre-intervention data serving as the control. The primary outcome is whether delivery of the Toolkit to primary care practices results in a monthly increase in number of initial LDCT screenings. Six participating centers will identify 10 practices and reach 2-3 providers per practice to train them to use the Toolkit. The Toolkit will address known barriers to screening and referral at the patient and provider levels and provide support for required elements of screening. Toolkit components include adaptable evidence-based interventions to maximize compatibility with workflows. We hypothesize that after nine months of intervention delivery, the number of initial screening per center will double. Involving 60 practices achieves 80% power at 5% level of significance. Implementation outcomes such as adoption, acceptability, feasibility, adaptation, and sustainability will be assessed through field-notes and activity logs. LDCT for lung cancer screening currently reaches a small fraction of eligible adults. To reach the full potential to reduce mortality, primary care practices are an important venue for increasing appropriate referrals. This multidisciplinary trial will encourage acceptability and sustainability by using local knowledge and promoting partnership between providers and patients. Trial registration: ClinicalTrials.gov, NCT03958253.

Questions: What are the temporal and spatial variations of groundwater depth along topographic gradients in Neotropical savannas? Are patterns of tree density and species diversity along topographic gradients in Neotropical savannas controlled by water table depth? Do soil and groundwater nutrient concentrations differ along topographic gradients in Neotropical savannas? Location: Fire-protected savannas of central Brazil. Methods: Over 16 mo, we monitored temporal and spatial variations in groundwater levels using automated submersible pressure transducers installed in ten wells located along two topographic gradients (five wells per gradient) of 950 m and 1703 m in length, representing elevations of 47 and 37 m a.s.l., respectively. We located the wells according to changes in vegetation physiognomies from woody savannas at high elevations, to open shrubby grasslands at low elevations. Along each topographic gradient we determined soil and groundwater nutrient concentrations as well as richness, density, basal diameter and height of trees within two plots of 14 × 14 m (392 m2) adjacent to each well. Results: Along the two gradients, groundwater levels exhibited larger fluctuations at lower than at higher elevations where the water table was deeper. Richness, density and diversity of trees decreased significantly at lower elevations where soils were waterlogged during the wet season. Soil pH and soil concentrations of carbon, nitrogen and manganese decreased significantly as elevation increased along the topographic gradients, but soil nutrient concentrations of phosphorus, aluminium and iron did not change with elevation. Groundwater samples contained only trace amounts of nutrients and were poorly correlated with elevation along the topographic gradients. Conclusions: In Neotropical savannas, the minimum distance between the soil surface and water table depth (reached during the wet season) and the relatively large fluctuations in groundwater limit tree density and diversity at low elevations as savanna trees cannot cope with extended waterlogging during the wet season and with low soil water availability during the dry season. Thus, variations of tree density and diversity along topographic gradients are more related to spatial and temporal variations in water table depth than to soil and groundwater nutrient variations in Neotropical savannas. Fil: Villalobos Vega, Randol. University of Technology; Australia Fil: Salazar, Ana. Miami University; Estados Unidos Fil: Miralles Wilhelm, Fernando. University of Maryland; Estados Unidos Fil: Haridasan, Mundayatan. Universidade do Brasília; Brasil Fil: Franco, Augusto C.. Universidade do Brasília; Brasil Fil: Goldstein, Guillermo Hernan. Universidad de Buenos Aires. Facultad de Ciencias Exactas y Naturales. Departamento de Ecología, Genética y Evolución. Laboratorio de Ecología Funcional; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina

The incidence of multiple myeloma is increasing as the proportion of older adults is growing rapidly. A critical evaluation of the evidence available is needed to guide the management of older patients with myeloma. A systematic review was conducted to report the prognostic value of geriatric assessment and frailty scores in older patients with multiple myeloma. We conducted a literature search in February and August 2018. Two researchers extracted the data and assessed the quality of the studies. Geriatric assessment and frailty scores were defined as those evaluating at least 2 geriatric domains. Main outcomes were mortality or toxicity. We estimated the pooled hazard ratios (HR) with 95% confidence intervals (CIs) using a random-effects model. We screened titles and abstracts of 1672 citations for eligibility. Seven studies were included in the qualitative analysis, of which 3 were included in the meta-analysis. Two studies reported similar risks of hematologic adverse events in intermediate-fit and in frail patients compared to frail, but a significantly increased risk of nonhematologic adverse events in frail patients compared to fit patients. In meta-analysis, a significantly increased HR for death was observed in patients with activity of daily living score ≤ 4 (pooled HR = 1.576; 95% CI, 1.051-2.102; χ2 = 0.87; P = .647; I2 = 0). Patients classified as frail showed higher risk of death than fit patients (pooled HR = 2.169; 95% CI, 1.002-2.336; χ2 = 3.02; P = .221; I2 = 33.7%). GA and frailty score are effective in predicting mortality in older adults with myeloma.

Little is known about the effects of fire on the structure and species composition of Neotropical savanna seedling communities. Such effects are critical for predicting long-term changes in plant distribution patterns in these ecosystems. We quantified richness and density of seedlings within 144 plots of 1 m2 located along a topographic gradient in long-unburned (fire protected since 1983) and recently burned (September 2005) savannas in Brazil. These savannas differ in tree density and canopy cover. Sites along the gradient, however, did not differ in species composition prior to the fire. In recently burned savannas we also evaluated the contribution of vegetative reproduction relative to sexual reproduction by quantifying richness and density of root suckers. Finally, we tested seed tolerance to pulses of high temperatures—similar to those occurring during fires on the soil surface and below—of five dominant savanna tree species. Seedlings were more abundant and diverse in unburned than in burned savannas. Seedling species composition differed among unburned and burned savannas probably reflecting early differences in root: shoot biomass allocation patterns. In recently burned savannas, root suckers were more abundant and diverse than seedlings. Relatively long exposures (>10 min) of temperatures of 90 °C reduced seed germination in all studied species suggesting a negative effect of fire on germination of seeds located at or aboveground level. Because vegetative reproduction contributes more than sexual reproduction in burned environments, frequent fires are likely to cause major shifts in species composition of Neotropical savanna plant communities, favoring clonally produced recruits along tree density/topographic gradients. Pouco se sabe sobre os efeitos do fogo sobre a estrutura e florística de comunidades de plântulas em savanas Neotropicais. No Brasil Central, foram quantificadas riqueza e densidade de plântulas dentro de 144 parcelas de 1 m2 localizadas ao longo de um gradiente de densidade de árvores. A área estudada foi exposta a diferentes regimes de fogo no passado e inclui parcelas queimadas dois anos antes do início do estudo (Setembro 2005) e parcelas não expostas ao fogo nos últimos trinta anos. Essas savanas diferem em densidade de árvores, de savanas fechadas a abertas. As área estudadas não diferiram na composição específica antes do fogo. Também foi avaliado o efeito de choques térmicos na germinação de cinco espécies arbóreas dominantes das savanas. A riqueza e densidade de plântulas foi menor em savanas recentemente queimadas do que em savannas não quemadas. Em savanas recentemente queimadas, brotos vegetativos de raíz foram mais abundantes e diversos do que plântulas. A composição específica de plântulas diferiu entre savanas dependendo do regime de queimada, provavelmente refletindo diferenças nos padrões de alocação de biomassa raiz: parte aérea. Exposições longas (>10 min) de temperaturas de 90 °C reduziram a germinação em todas as espécies estudadas, sugerindo um efeito negativo do fogo sobre a germinação de sementes localizadas sob a superfície do solo. Devido ao fato que a reprodução vegetativa contribui mas do que a reprodução sexual após queimadas, queimadas frequentes podem causar mudanças na composição de espécies das comunidades vegetais de savanas Neotropicais, favorecendo indivíduos com reprodução vegetativa. Fil: Salazar, Ana. University of Miami; Estados Unidos Fil: Goldstein, Guillermo Hernan. University of Miami; Estados Unidos. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Ciudad Universitaria. Instituto de Ecología, Genética y Evolución de Buenos Aires. Universidad de Buenos Aires. Facultad de Ciencias Exactas y Naturales. Instituto de Ecología, Genética y Evolución de Buenos Aires; Argentina

The failure of seeds to arrive at all suitable sites (seed limitation) greatly affects plant distribution and abundance. In contrast to tropical forests, the degree of seed limitation in Neotropical savannas is unclear because empirical studies at the community level are scarce. We estimated seed limitation of 23 woody species from annual seed rain measurements along a tree density gradient in the savannas of Central Brazil. These savannas differ in tree density and canopy cover, from closed to open savannas, and are located along shallow topographic gradients. We also studied post-dispersal seed predation and removal of 17 representative woody species, and seed viability loss over time of 12 common woody species under dry-storage conditions. Annual seed rain was lower in open (410 seeds/m 2) than in closed savannas (773 seeds/m 2). Average seed limitation across woody species was higher than 80% along the tree density gradient. More than 60% of seeds of the studied woody species were predated or removed within 30-45 days in all savannah types. Seeds of most common woody species (66%) lost their viability in less than 12 months of dry storage. This study shows that Neotropical savannah woody plants are strongly seed-limited because of low and poor distribution of seeds among sites, post-dispersal seed removal, and short seed longevity. The high seed limitation of tree species in Neotropical savannas, particularly in open savannas, also may contribute to maintain their relatively low tree densities and help to explain the spatial variation of tree abundance along topographic gradients. Fil: Salazar, Ana. University of Miami; Estados Unidos Fil: Goldstein, Guillermo Hernan. University of Miami; Estados Unidos. Universidad de Buenos Aires. Facultad de Ciencias Exactas y Naturales. Departamento de Ecología, Genética y Evolución; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Franco, Augusto C.. Universidade do Brasília; Brasil Fil: Miralles Wilhelm, Fernando. Florida International University; Estados Unidos

A large fraction of tree species forming persistent soil seed-banks and with dormant seeds are expected to be found in strongly seasonal ecosystems such as Neotropical savannas, where seedling recruitment could be highly variable. In the savannas of Central Brazil, we studied seed characteristics (type of dormancy, longevity and moisture content) of 14 representative woody species differing in seed dispersal season. We also studied the dynamics of soil seed-banks and similarity patterns in woody species composition among seed rain, soil seed-bank, seedling bank and standing vegetation along shallow topographic gradients that differ in canopy cover. Woody species composition of the soil seed-bank largely differed from the standing vegetation, the seed rain and the seedling bank species composition, suggesting low recruitment of woody species from the soil seed-bank. Seeds of the 14 woody species remained viable for less than 16 months in laboratory dry-storage conditions. Of those, most seeds dispersed in the dry season were dormant and exhibited low moisture content, while most seeds dispersed in the wet season were non-dormant and exhibited high moisture content. Longevity of these seeds dispersed in the dry and the wet seasons did not differ significantly. This study shows that both timing of seed dispersal and dormancy appear to control timing of seed germination and seedling recruitment of most Neotropical savanna woody species, which did not form persistent soil seed-banks. This study contributes to the understanding of tree/grass coexistence and tree density variations along topographic gradients in tropical savannas.

Background Candida bloodstream infection (CBSI) is associated with high morbidity and mortality. Guidelines recommend echinocandins as initial therapy, with fluconazole as an acceptable alternative in selected patients, including those at low risk for fluconazole resistance. We aimed to create a predictive model to identify patient at high risk of fluconazole resistance. Methods We performed a retrospective analysis of hospitalized patients with CBSI at a large tertiary referral hospital between January 2007 and January 2015. Data were collected on demographics, comorbidities, medications, procedures, central lines, vital signs, and laboratory values. Univariate and multivariable logistic regression analyses were used to build the predictive model. Variables with P < 0.25 were considered for the multivariable analysis, and only those that remain significant (P < 0.05) were retained in the final model. Results We identified 1,083 patients with CBSI, of whom 684 patients had azole susceptibility data available. Among cases with available resistance data, C. glabrata was the most common species isolated, occurring in 240 cases (38%), followed by C. parapsilosis, 176 cases (25.7%), and C. albicans, 121 cases (17.6%). One hundred thiry-nine isolates were found to have fluconazole resistance (C. glabrata 55, C. krusei 36). Eighty-three variables were considered in the multivariable analysis; nine remained significant and were included in our final model. Variables associated with a higher risk of fluconazole resistance were: hematological cancer (OR 1.69 [95% CI 1.03, 2.79]), presence of an indwelling line (2.00 [1.30, 3.10]), prior fluconazole use (2.46 [1.32, 4.56]), prior voriconazole use (10.89 [1.18, 99.84]), prior calcineurin inhibitor use (2.65 [1.24, 5.66]), prior nitroimidazole use (1.63 [1.01, 2.64]), and prior tetracycline use (4.77 [1.96, 11.64]). Isolation of C. parapsilosis (0.20 [0.10, 0.39]), and chronic pulmonary disease (0.43 [0.21, 0.87]) were associated with a lower risk of resistance. The final model had a C-statistic of 0.75. Conclusion We identified nine risk factors that were significantly associated with fluconazole resistance. By creating a predictive model, patients at higher or lower risk for resistance may be identified earlier which may assist in the choice of initial antifungal treatment. Disclosures All authors: No reported disclosures.

Background Candida endocarditis (CE) is a rare but an invasive infection associated with a high mortality rate. The current understanding of this infection is poorly defined from case reports, case series and small cohorts. This study aimed to assess the risk factors for CE in patients with candida bloodstream infections (CBSI). Methods We conducted a retrospective analysis of all hospitalized patients diagnosed with CBSI at a large tertiary care hospital between 2002 and 2015. Data included demographics, comorbidities, laboratory parameters, and outcomes. Univariate and multivariable logistic regression analyses were used to build the predictive model. Results Of 1,873 cases of CBSI, 47 patients were identified to have CE. The most commonly isolated species were C. albicans (59.6%) followed by C. parapsilosis (16.2%). On univariate analysis, preexisting valvular disease (7.95, 95% CI [3.16, 20.02]) was associated with a higher risk of CE (P < 0.05). Factors such as isolation of C. glabrata (0.17, 95% CI [0.04, 0.68]), hematologic malignancy (0.09, 95% CI [0.01, 0.68]), and total parenteral nutrition (TPN) (0.40, 95% CI [0.17, 0.95]) were all associated with a lower risk of CE. In multivariable modeling, the factors of valvular disease (5.05, 95% CI [1.77, 14.43]), isolation of C. glabrata (0.19, 95% CI [0.05, 0.80]), hematologic malignancy (0.09, 95% CI [0.01, 0.66]), and total parenteral feeding (0.43, 95% CI [0.17, 1.09]) remained significant. The final model had a C-statistic of 0.82. The crude 90-day mortality for CE was 48.9%, similar to the overall CBSI mortality of 42.1%. Conclusion In a population of patients with CBSI, previous valvular disease was the only factor associated with a greater risk of development of CE. Use of TPN, hematologic malignancy, and isolation of C. glabrata were protective factors. A predictive model may reduce the need for expensive and sometimes invasive diagnostic imaging such as trans-esophageal echocardiography, as a subset of patients may be at low enough risk for CE not to warrant them. Disclosures All authors: No reported disclosures.

Background Cryptococcal disease (CD) often has an insidious presentation and can be difficult to recognize. However, delayed diagnosis can lead to increased morbidity and mortality. Methods To estimate the potential number of missed opportunities for CD diagnosis we utilized the Healthcare Cost and Utilization Project State Inpatient Database from the Agency for Healthcare Research and Quality for the state of Florida from 2005 to 2014. We defined a missed opportunity as an admission with a new diagnosis of CD preceded by a hospitalization in the prior 90-days coded for an infection, respiratory, or central nervous system condition suggestive of CD. We performed descriptive statistics including mortality in each exposure group within one year after CD diagnosis. Results We identified 1,622 CD-related hospital discharges in Florida from April 2005 to December 2014. The median age of CD patients was 47 years, 30.6% were female, and 55.5% were coded for HIV/AIDS. Of those, 850/1,622 (52.4%) had meningitis. Five hundred sixty (34.5%) had a prior hospitalization within 90 days before the first hospitalization coded for CD. Of those, 50.9% (285/560) had a potentially missed opportunity to diagnose CD of whom 138/285 (48.4%) were HIV-positive. Of 560 patients, 49 (8.7%) were coded during a prior hospitalization with CNS conditions, 162 (28.9%) with respiratory conditions and 74 (13.2%) coded with both CNS and respiratory conditions. Patients who were coded for CNS diagnoses in a prior admission were more likely to be diagnosed with CD meningitis (P < 0.001). Of those with prior respiratory conditions 29/218 (13.3%) died during the CD admission, and 12.5% of those with prior CNS conditions died during the CD admission. Of those without a prior admission in the past 90 days, 110/1,062 (10.4%) died during the CD admission. Conclusion Cryptococcosis is a deadly disease that affects patients with both competent and incompetent immune systems. Missed opportunities to diagnose CD are relatively commonmand may contribute to worse outcomes. Disclosures All authors: No reported disclosures.

The objective of this study was to characterize and understand morphological and physiological variation in traits related to water economy, at the plant and stand level, along a gradient of tree density in a Neotropical savanna (Cerrado). Cerrado plots subjected to long-term fertilization and gallery forests were also included in the analysis to expand the axes of ecosystem variation. Consistent changes in stand level biophysical traits observed along the gradient of increasing tree density included a decrease in weighted-average wood density, and increases in leaf surface area per plant, leaf specific hydraulic conductivity, specific leaf area and stomatal conductance. A conceptual model of biophysical, morphological and physiological trait interactions was developed in an attempt to explain determinants of hydraulic architecture and variations in water economy of Cerrado trees. Consistent with the model minimum leaf water potentials were higher, during the dry season, in low wood density trees compared to high wood density trees, and higher leaf water potential was associated with higher stomatal conductance. On the other hand, variations in stand level physiological and morphological traits along the tree density gradient could not be explained by variations in single environmental factors. Some of the potential contributing factors are: higher concentration and availability of soil nutrients in the upper portion of the gradient where tree density is greatest and constrains to tree establishment and growth by waterlogging and presence of concretions in the soil profile where tree density is lowest. Key words: gallery forest, hydraulic architecture, nutrients, savannas, specific leaf area, wood densitygallery forest, hydraulic architecture, nutrients, savannas, specific leaf area, wood density O objetivo deste estudo foi caracterizar e compreender as variações morfológicas e fisiológicas em atributos relacionados à economia da água, em nível de indivíduo e de parcela, que ocorrem ao longo de um gradiente de densidade arbórea em uma savana neotropical (cerrado). Parcelas de vegetação de cerrado submetidas a um experimento de adubação de longo prazo e matas de galeria também foram incluídas na análise, a fim de expandir os eixos de variação do ecossistema. Mudanças consistentes em atributos biofísicos em nível de parcela foram observadas ao longo do gradiente de densidade crescente de árvores. Estas incluíram uma diminuição na densidade média ponderada da madeira, aumentos na área foliar por planta, na condutividade hidráulica específica da folha, na área foliar específica e na condutância estomática. Um modelo conceitual das interações entre as características biofísicas, morfológicas e fisiológicas foi desenvolvido em uma tentativa de explicar os determinantes da arquitetura hidráulica e variações na economia de água de árvores do Cerrado. Consistente com o modelo, os valores mínimos de potencial hídrico durante a estação seca foram maiores nas árvores de baixa densidade de madeira, em comparação com árvores de alta densidade de madeira, enquanto os maiores valores de potencial hídrico foliar estiveram associados com maior condutância estomática. Por outro lado, ao longo do gradiente de densidade arbórea, as variações em nível de parcela das características morfológicas e fisiológicas não puderam ser explicadas por variações de um único fator ambiental. Alguns dos fatores contribuintes potenciais são: maior concentração e disponibilidade de nutrientes do solo na porção superior do gradiente de densidade arbórea onde há um maior número de árvores e restrições no estabelecimento e crescimento pela inundação periódica e pela presença de concreções no perfil do solo onde a densidade de árvores é mais baixa Fil: Scholz, Fabian Gustavo. Universidad Nacional de la Patagonia "San Juan Bosco"; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Bucci, Sandra Janet. Universidad Nacional de la Patagonia "San Juan Bosco". Instituto de Biociencias de la Patagonia. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Centro Nacional Patagónico. Instituto de Biociencias de la Patagonia; Argentina Fil: Goldstein, Guillermo Hernan. University of Miami; Estados Unidos. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Ciudad Universitaria. Instituto de Ecología, Genética y Evolución de Buenos Aires. Universidad de Buenos Aires. Facultad de Ciencias Exactas y Naturales. Instituto de Ecología, Genética y Evolución de Buenos Aires; Argentina Fil: Meinzer, Frederick C.. Forestry Sciences Laboratory; Estados Unidos Fil: Franco, Augusto C.. Universidade do Brasília; Brasil Fil: Salazar, Ana Inés. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Miami University; Estados Unidos