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Background Medical device infections caused by nontuberculous mycobacteria (NTM) are increasingly reported in the literature. Management is complex and often guided by expert opinion, in the absence of evidence-based guidelines. Methods We searched available databases for reports of‌ implantable‌ cardiac device-related‌ (ICDR) infections with NTM. We collected patient-level characteristics, microbiological, and treatment data, and used univariate analysis to correlate with reported outcome, which we defined as death, treatment failure, relapse after treatment completion, cure, and treatment completion. Results Of 2573 potential eligible articles, 68 articles were included, representing 112 patients. The average patient age was 61 years, and 6% of patients were immunocompromised. Of 12 species reported, 65% were rapid growers, with M. fortuitum most common. Prosthetic heart valves and pacemaker/automatic implantable cardiac devices (AICD) were the most commonly reported infected devices (45% and 37%, respectively). Diagnosis was often delayed, and confirmed with culture (62%, 41% blood cultures) and 16s ribosomal RNA gene sequencing data (14%) of cases. Antimicrobial susceptibility was available in 55% of cases. 70% of patients received >2 antibiotics and, of these, 41% included a macrolide. Devices were removed for 65% of patients, more commonly if the infected deice was a pacemaker or AICD than another type of cardiac device (86% vs 56%, p=0.02). 67% of patients with prosthetic valves underwent valve replacement. Compared with those who did not have their device removed, patients who underwent device removal were less likely to die (23% vs 48%, p=0.02) and more likely to have favorable outcomes (68% vs 28%, p=0.002). Conclusion Reports of ICRD NTM infections were common, and suspicion should be high even for those without immunocompromising condition. Determining outcome was challenging and should be standardized to provide an evidence base for better management. In our analysis, patients who underwent device removal had improved survival, suggesting either that comorbidity precluded device removal and/or that removal may be an essential part of the management. Disclosures All Authors: No reported disclosures.

UNSTRUCTURED People who inject drugs are at increased risk of Hepatitis C (HCV) and human immunodeficiency virus (HIV); unfortunately, traditional healthcare approaches have failed to adequately reach and support this population. Rates of accessing HCV and HIV treatment among individuals who inject drugs are low for a variety of reasons, including negative experiences with healthcare, suggesting a need for novel approaches to testing and healthcare delivery. In this short report we discuss challenges - as well as strategies to navigate these challenges - encountered by a multidisciplinary team of healthcare professionals, community representatives, researchers, and people with lived experience using drugs, in our efforts to co-produce a novel, community-based, peer-led, HIV/HCV testing program with options for immediate linkages to medical providers. We encountered challenges and tensions between team members with varied background in multiple aspects of the project: scoping the project, setting the pace and urgency of the work, navigating payment, defining success, and situating the project for sustainability. Strategies to navigate these challenges included: dedicated effort to building personal and meaningful connections, fostering mutual respect, identifying common ground to make shared decisions, and celebrating small successes. While co-created care presents unique challenges, we believe the resulting program is strengthened by challenging assumptions and carefully considering various perspectives to think creatively and productively about solutions.

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately impacted lesbian, gay, bisexual, transgender, and queer (LGBTQ+) communities. Many disparities mirror those of the human immunodeficiency virus (HIV)/AIDS epidemic. These health inequities have repeated throughout history due to the structural oppression of LGBTQ+ people. We aim to demonstrate that the familiar patterns of LGBTQ+ health disparities reflect a perpetuating, deeply rooted cycle of injustice imposed on LGBTQ+ people. Here, we contextualize COVID-19 inequities through the history of the HIV/AIDS crisis, describe manifestations of LGBTQ+ structural oppression exacerbated by the pandemic, and provide recommendations for medical professionals and institutions seeking to reduce health inequities.

To assess the challenges of managing diabetes experienced by clients of a community-based social services organization via qualitative interviews; to develop recommendations for more effective diabetes education programming at the organization based on themes identified in the interviews.Staff at Progreso Latino in Central Falls recruited clients with diabetes and prediabetes to participate in interviews during the summer of 2019. Each interview used a structured question set and was conducted in the participant's preferred language of Spanish or English. Investigators analyzed the interview transcripts and identified predominant themes.Analysis of fourteen interviews yielded four predominant themes: uncertainty about diagnosis and treatment, fear as part of the discussion with providers, language barriers, and cultural barriers.To strengthen diabetes education programming at a community-based organization, we recommend utilization of community health workers, development of culturally appropriate dietary recommendations, and creation of educational videos in clients' preferred languages.

UNSTRUCTURED As the conversation continues in addressing racial healthcare disparities nationwide not much has been written from a rural perspective. One important way to improve racial healthcare disparities in rural America is investing in training, hiring, and better supporting underrepresented minority clinicians that treat racial and ethnic minority patients in rural settings. The viewpoint will identify the problem we currently have in graduate medical education and offer suggestions for improvement.

Esophageal adenocarcinoma is an increasingly common cause of morbidity and mortality in developed countries. Most cases are considered the consequence of chronic gastroesophageal reflux disease, with subsequent Barrett's metaplasia and dysplasia. Because progression from Barrett's metaplasia to cancer occurs over many years, endoscopic screening and surveillance programs have been established, albeit with little or no consideration for cost-effectiveness. As an alternative to the expensive and resource-demanding endoscopic surveillance, the Cytosponge has been developed to sample the esophageal mucosa efficiently. The device is a compressed mesh sponge encapsulated in an ingestible gelatin pill attached to a string. After swallowing, the capsule dissolves allowing the sponge to expand in the stomach. As it is pulled out, cells are collected from the esophagogastric junction and throughout the esophagus. The cellular samples can be analyzed by cytology, immunohistochemistry, and molecular markers. We conducted a systematic review of all recent relevant studies to help define the role of this novel technology, including studies of screening and surveillance of Barrett's esophagus, esophageal squamous dysplasia detection, detection of eosinophilic esophagitis, and evaluation of benign esophageal diseases. With the major limitation that most studies were performed by a single investigative group that developed the technology, the device yielded overall impressive results against the endoscopy/biopsy gold standard. Patient acceptability was high. If these promising early results are validated by other investigators in other populations, the Cytosponge represents an important new advance in the detection of esophageal pathology that could potentially decrease the burden of endoscopic esophageal sampling.

Introduction Approximately 30% of all outpatient antimicrobials are inappropriately prescribed. Currently, antimicrobial prescribing patterns in emergency departments (ED) are not well described. Determining inappropriate antimicrobial prescribing patterns and opportunities for interventions by antimicrobial stewardship programs (ASP) are needed. Methods A retrospective chart review was performed among a random sample of non-admitted, adult patients who received an antimicrobial prescription in the ED from January 1 to December 31, 2015. Appropriateness was measured using the Medication Appropriateness Index, and was based on provider adherence to local guidelines. Additional information collected included patient characteristics, initial diagnoses, and other chronic medication use. Results Of 1579 ED antibiotic prescriptions in 2015, we reviewed a total of 159 (10.1%) prescription records. The most frequently prescribed antimicrobial classes included penicillins (22.6%), macrolides (20.8%), cephalosporins (17.6%), and fluoroquinolones (17.0%). The most common indications for antibiotics were bronchitis or upper respiratory tract infection (URTI) (35.1%), followed by skin and soft tissue infection (SSTI) (25.0%), both of which were the most common reason for unnecessary prescribing (28.9% of bronchitis/URTIs, 25.6% of SSTIs). Of the antimicrobial prescriptions reviewed, 39% met criteria for inappropriateness. Among 78 prescriptions with a consensus on appropriate indications, 13.8% had inappropriate dosing, duration, or expense. Conclusion Consistent with national outpatient prescribing, inappropriate antibiotic prescribing in the ED occurred in 39% of cases with the highest rates observed among patients with bronchitis, URTI, and SSTI. Antimicrobial stewardship programs may benefit by focusing on initiatives for these conditions among ED patients. Moreover, creation of local guideline pocketbooks for these and other conditions may serve to improve prescribing practices and meet the Core Elements of Outpatient Stewardship recommended by the Centers for Disease Control and Prevention.

Objective Several studies show that chronic opioid dependence leads to higher in-hospital mortality, increased risk of hospital readmissions, and worse outcomes in trauma cases. However, the association of outpatient prescription opioid use on morbidity and mortality has not been adequately evaluated in a critical care setting. The purpose of this study was to determine if there is an association between chronic opioid use and mortality after an ICU admission. Design A single-center, longitudinal retrospective cohort study of all Intensive Care Unit (ICU) patients admitted to a tertiary-care academic medical center from 2001 to 2012 using the MIMIC-III database. Setting Medical Information Mart for Intensive Care III database based in the United States. Patients Adult patients 18 years and older were included. Exclusion criteria comprised of patients who expired during their hospital stay or presented with overdose; patients with cancer, anoxic brain injury, non-prescription opioid use; or if an accurate medication reconciliation was unable to be obtained. Patients prescribed chronic opioids were compared with those who had not been prescribed opioids in the outpatient setting. Interventions None. Measurements and main results The final sample included a total of 22,385 patients, with 2,621 (11.7%) in the opioid group and 19,764 (88.3%) in the control group. After proceeding with bivariate analyses, statistically significant and clinically relevant differences were identified between opioid and non-opioid users in sex, length of hospital stay, and comorbidities. Opioid use was associated with increased mortality in both the 30-day and 1-year windows with a respective odds ratios of 1.81 (95% CI, 1.63–2.01; p Conclusions Chronic opioid usage was associated with increased hospital length of stay and increased mortality at both 30 days and 1 year after ICU admission. Knowledge of this will help providers make better choices in patient care and have a more informed risk-benefits discussion when prescribing opioids for chronic usage.

Background and Aims Acute cholangitis is characterized by abdominal pain, fever, and jaundice. Most patients respond to medical management with intravenous hydration and antibiotics. About 20% to 30% require biliary drainage, and ERCP is the procedure of choice. We conducted a systematic review and meta-analysis to evaluate the impact of emergent biliary drainage on patient outcomes. Methods A comprehensive literature review was conducted by searching the Embase and PubMed databases from inception to April 2019 to identify all studies that evaluated the impact of timing of ERCP on patient outcomes. Our primary outcome was in-hospital mortality (IHM), and secondary outcomes were length of stay (LOS), organ failure, and 30-day mortality. Fixed and random effects models were used to generate pooled measures of IHM, 30-day mortality, and LOS. Results Nine observational studies involving 7534 patients were included in the primary meta-analysis. IHM was significantly lower in patients who underwent emergent biliary drainage within 48 hours (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.28-0.98). As a sensitivity analysis, we pooled the data from 2 population registry studies of 81,893 patients, which yielded consistent results for the main outcomes. LOS was also significantly lower in patients who underwent ERCP within 48 hours with a mean difference of 5.56 days (95% CI, 1.59-9.53). Patients who underwent emergent ERCP also had lower odds of 30-day mortality (OR, 0.39; 95% CI, 0.14-1.08) and organ failure (OR, 0.69; 95% CI, 0.33-1.46). Conclusions Our study reveals that performing emergent ERCP within 48 hours in patients with acute cholangitis is associated with lower IHM, 30-day mortality, organ failure, and shorter LOS.

Objective To assess and compare the diagnostic value of lactate, procalcitonin (PCT) and C-reactive protein (CRP) in low, moderate, and high-risk stratified population applying Mortality in Emergency Department (MEDS) risk score using Bayesian statistical modeling. Methods MEDS criteria was used to risk stratify into low, moderate and high risk. Each population was attributed a percentage risk, and used as pre-test probability in the Bayesian nomogram. Sensitivity and specificity lactate, PCT and CRP were attained from pooled meta-analysis data. Absolute and relative diagnostic gains were calculated. Results Pooled diagnostic quality data obtained from a meta-analysis reflected sensitivity for PCT of 77% and specificity of 79%, for lactate sensitivity 49.1% and specificity 74.3% and CRP yielded a sensitivity of 75% and specificity 67%. likelihood ratios (LR) calculations for PCT were LR + 3.67 and LR − 0.29; for lactate LR + 1.88 and LR − 0.69; CRP LR + 2.27 and LR − 0.37. When computed in Bayesian nomogram post-test probabilities for LR + were as follows: for PCT low risk absolute gain of 11.7% and relative gain of 220%; moderate absolute gain 25.7% relative gain 148.5%; for high risk absolute gain 25.1% and relative gain 42.6%. Lactate LR + results for low risk absolute gain of 4.7% and relative gain of 88.6%; moderate absolute gain 10.7% and relative gain 61.8%; high risk relative gain 14.1% and relative gain 23.9%. CRP results for low population and LR + absolute gain 5.7% and relative gain 107.5%; moderate risk 14.7% absolute gain and 84.9% relative gain; high risk 77% post-test 18.1% absolute gain and 30.7% relative gain. Conclusion Bayesian statistical model demonstrated the superior diagnostic quality of PCT. For ruling out severe disease, lactate yielded a higher benefit with increased relative gain with negative LR.

Background Prevention of Hepatitis C virus (HCV) infection and its associated health complications are a national priority. To achieve optimal health outcomes, people with HCV must receive the diagnosis, link to and retain in care and receive treatment. Despite recent progress in increasing capacity and improving access to care for patients with HCV in the United States, there continues to be a need to improve Hepatitis C care especially in primary care settings. This study sought to assess HCV care in a resident-run primary care clinic of a community hospital. Methods Retrospective study of active patients ≥18 years with a diagnosis of Hepatitis C in the electronic medical records (EMR) at 2 outpatient medicine clinics at a community hospital in Rhode Island. Patients were identified by searching the following diagnoses in the EMR: “chronic hepatitis C”, “chronic hepatitis C without coma,” “chronic hepatitis C with coma,” “reactive HCV serology,” “hepatocellular carcinoma.” Patients with HIV coinfection were excluded as these patients are usually referred to a specialty clinic outside the hospital’s network. Results Of 12,482 outpatients, 306 had a diagnosis of Hepatitis C. One hundred and fifty-nine (54%) of these patients had HCV RNA detected indicating chronic infection, 51 (17%) patients had reactive HCV antibodies and undetected HCV RNA indicating past infection, and 84 (29%) patients had positive serology to HCV but lacked HCV RNA testing. Obesity was associated with not having HCV RNA checked (OR 2.9, 95% CI 1.66-5.24). No differences observed for other variables although patients with a history of alcohol use had a tendency towards lacking HCV RNA testing (P = 0.08). The prevalence of confirmed chronic hepatitis C was 1.6%. Twenty-three (21%) patients with chronic hepatitis C had cirrhosis and 5 had hepatocellular carcinoma however only a minority of them (11%) had received or were receiving direct acting antivirals. Hepatitis B vaccination in HCV infected patients was low (39%). Conclusion A significant proportion of patients with reactive serology to HCV in our primary care clinics miss the critical step of having HCV RNA checked. Other medical conditions such as obesity may take priority over HCV care. Implementation of HCV targeted interventions could improve HCV care in primary care. Disclosures All authors: No reported disclosures.