Tasks, shortcomings and reservations in the process of reforming the specialized dermatovenereological sector of health care

Objective — to draw the attention of the Ukrainian health care management, the National Health Care Service (NHCS) and dermatovenereologists to urgent issues of reforming the industry, identifying shortcomings in the reform and presenting the views of experienced professionals on correcting organizational measures.Official statistics was used based on the materials of leading specialists of Kharkiv Research Institute of Dermatology and Venereology, scientific and practical institutions of Ukraine, the forecast of «GlobalData» analytical and statistical company on the trend of syphilis in the world, the results of discussion of current reform issues with leading specialists in dermatovenereology.The interpretation of the modern epidemiological panorama of skin and venereological pathology, the current state of organizational and material support of dermato-venereology institutions are presented. Some specific shortcomings and miscalculations in the process of reforming are revealed from the point of view of experienced specialists in the field, the authors’ vision of ways to improve the organization and activity of the dermatovenereological service of the country is presented.The need for correction in the process of reforming the specialized dermatovenereological service by resolving the urgent issue of organization in the areas of round-the-clock bed stock within reasonably adjusted limits and their financial and material support is substantiated. Calculations of the needs of round-the-clock inpatient beds in the regions should be carried out in the NHCS with the participation of the leadership of the Ukrainian Association of Dermatovenereologists and Cosmetologists (UADVC). The reforming of the dermatovenereology service should become a truly effective compo­nent of the generally progressive system of health care reform, taking into account the international medical and statistical forecasts.

Shifts in social support: A phenomenographic study of Nigerian women who have had a stillborn baby

<p>Each year in Nigeria 314,000 mothers lose their babies to stillbirth. This study investigates the implications of these stillbirths for Nigeria’s Yoruba women, especially in relation to their social networks. The study is theoretically framed within the theory of social capital and the research methodology is phenomenography, a qualitative approach that concerns itself with difference in relation to experience. Twenty mothers of stillborn babies were purposefully recruited from Saki, a Yoruba community in South-west Nigeria. Data were collected through semi-structured interviews, participants’ drawings and a focus group discussion. The transcribed data were analysed according to the principles of phenomenography. This yielded four broad categories: (1) relationships change; (2) relationships matter; (3) material support makes a difference; and (4) health professionals neither help nor support. These findings indicated that stillbirth interfered with the social networks of the participants, leading to a decline in their social networks and an emergence of the family as the primary source of support. The participants gained encouragement and empathy through their relationships with others but received minimal material support, even though it was badly needed. The participants expressed distrust in health professionals due to a lack of compassionate care. This study contributes to the understanding of stillbirth bereavement in three different ways. First, culture really matters in how mothers of stillborn babies express their grief, how they are supported and how they would want to be supported. Second, there is still a deficit of kind, compassionate and skilled nursing care for mothers of stillborn babies. Third, support becomes smaller, but more intense for mothers after suffering a stillbirth. This study, therefore, adds to the ongoing global conversations about how better bereavement care can become more realistic for mothers of stillborn babies by extending the theory of social capital and the methodological approach of phenomenography to the issue of stillbirth bereavement. The study concludes with recommendations for nursing, for research and for policy.</p>

Shifts in social support: A phenomenographic study of Nigerian women who have had a stillborn baby

<p>Each year in Nigeria 314,000 mothers lose their babies to stillbirth. This study investigates the implications of these stillbirths for Nigeria’s Yoruba women, especially in relation to their social networks. The study is theoretically framed within the theory of social capital and the research methodology is phenomenography, a qualitative approach that concerns itself with difference in relation to experience. Twenty mothers of stillborn babies were purposefully recruited from Saki, a Yoruba community in South-west Nigeria. Data were collected through semi-structured interviews, participants’ drawings and a focus group discussion. The transcribed data were analysed according to the principles of phenomenography. This yielded four broad categories: (1) relationships change; (2) relationships matter; (3) material support makes a difference; and (4) health professionals neither help nor support. These findings indicated that stillbirth interfered with the social networks of the participants, leading to a decline in their social networks and an emergence of the family as the primary source of support. The participants gained encouragement and empathy through their relationships with others but received minimal material support, even though it was badly needed. The participants expressed distrust in health professionals due to a lack of compassionate care. This study contributes to the understanding of stillbirth bereavement in three different ways. First, culture really matters in how mothers of stillborn babies express their grief, how they are supported and how they would want to be supported. Second, there is still a deficit of kind, compassionate and skilled nursing care for mothers of stillborn babies. Third, support becomes smaller, but more intense for mothers after suffering a stillbirth. This study, therefore, adds to the ongoing global conversations about how better bereavement care can become more realistic for mothers of stillborn babies by extending the theory of social capital and the methodological approach of phenomenography to the issue of stillbirth bereavement. The study concludes with recommendations for nursing, for research and for policy.</p>

Praying through the pandemic: Religion, uncertainty, and care

Throughout the Covid-19 pandemic, Roma Pentecostal converts in England continued to meet for religious gatherings and communal prayer, either outdoors or in private homes of church members, despite measures put in place by the British government that limited the number of social contacts between individuals and at times forbade visiting other households. Among the members of the Life and Light church are many who belong to one of the high-risk categories for complications from Covid-19. Why would converts take part in activities that involved increased risk of virus transmission and increase their possibility of getting ill? This paper draws on informal online and in-person conversations with Roma that took place during the summer and autumn of 2020 and reflects on religion and communal prayer as a strategy of coping with the heightened uncertainty brought by the pandemic. It argues that participating in religious meetings where people jointly pray for others, both those who present and those who are absent, is an intangible form of care that helps to forge, shape, and maintain social relationships and creates a sense of belonging and continuity. In addition, praying is an embodied expression of one’s relationship to a transcendental entity, Jesus, and of placing oneself into the caring hands of God and Jesus. Lastly, the Church provides material support for members who are in a difficult financial situation. Participating in Church activities like prayer meetings is an expression of belonging to a religious collectivity and can help gain access to this material help in situations when access to state-provided care and material support is limited or absent, thus opening for church members the possibility of tangible forms of care. The paper looks at the role of religion in dealing with the uncertainty that Roma migrants experience when dealing with the state and going about their everyday lives and the upheaval and increased uncertainty brought by the pandemic.

509. Clinical Characteristics and Outcomes in Patients Infected with SARS-CoV-2 Treated with Remdesivir, Tocilizumab, and/or Dexamethasone at a Mid-Atlantic Hospital Consortium

Background Treatment strategies for COVID-19 have evolved based on clinical trials. We performed a retrospective analysis to determine treatment outcomes for Remdesivir (RDV), Tocilizumab (TOCI), and/or Dexamethasone (DEX) in a representative population from the Mid-Atlantic region. Methods A retrospective chart review was performed for patients admitted to MedStar hospitals within the D.C./Baltimore corridor from 03/01/2020 to 12/31/2020, and diagnosed with COVID-19 using a NP SARS-CoV-2 RT PCR assay. The MedStar Pharmacy Database was utilized to stratify based on any combination of RDV, TOCI, DEX treatment. Our primary endpoints included O2 delivery device, length of stay (LOS), and mortality. Results A total of 2488 patients were included. Overall, the average age of patients was 62yrs, 53% male, and the majority of patients were of Black (54%) or White (27%) race. The average length of stay was 11 days (SD = 12) with a mortality of 14%. Using univariate analyses, all combinations of RDV, TOCI, and DEX treatment regimens were evaluated. Patients who received DEX required the most ventilatory support on Day 1 (5%, p&lt; 0.001) compared to all other groups. These same patients, however, did not go on to have higher ventilatory needs (17%, p&lt; 0.001) compared to the group which ultimately required the most ventilatory support, TOCI plus DEX (94%, p&lt; 0.001) at Day 28 of treatment. TOCI use alone was associated with a 4% to 63% (p&lt; 0.001) increase in need for ventilatory support over the course of 28 days (Figure 1). The shortest LOS was seen in those treated with DEX alone (9.5 days, p&lt; 0.001). Longer LOS outcomes were associated with all treatment groups which included TOCI use (19 to 22 days, p&lt; 0.001, Figure 2). Mortality was similarly higher among all treatment groups which contained TOCI (30% to 62.5%, p&lt; 0.001, Figure 3) when compared to those with RDV and/or DEX use alone (10% to 14%, p&lt; 0.001). Barplot of Oxygen Delivery Device at Admission and within 28 Days among Treatments Figure 1. Largest increase in ventilatory support from Day 1 of treatment (left) to Day 28 of treatment (right) was seen among TOCI and DEX (0% to 93.8%), RDV and TOCI (0% to 72.2%) and TOCI alone (3.7% to 63.4%). Figure 2. LOS was higher among all treatments containing TOCI (p&lt;0.001), with the highest being the combination group of RDV, TOCI, and DEX (22.4 days, p&lt;0.001). Figure 3. Treatment regimens containing TOCI accounted for the highest mortality rates as seen in TOCI and DEX use (62.5%), RDV and TOCI (44.4%), and TOCI use alone (30.4%). Conclusion Our study demonstrates that “real-world” clinical outcomes for patients with COVID-19 treated with Remdesivir, Tocilizumab, and Dexamethasone are consistent with what has been reported in clinical trials. The higher mortality associated with Tocilizumab treatment may reflect the use of this agent in critically ill patients with COVID-19. Disclosures Princy N. Kumar, MD, AMGEN (Other Financial or Material Support, Honoraria)Eli Lilly (Grant/Research Support)Gilead (Grant/Research Support, Shareholder, Other Financial or Material Support, Honoraria)GSK (Grant/Research Support, Shareholder, Other Financial or Material Support, Honoraria)Merck & Co., Inc. (Grant/Research Support, Shareholder, Other Financial or Material Support, Honoraria)

44. Impact of Nursing Home (NH) Universal Decolonization and COVID Prevention Training on COVID-19 Burden During the 2020-2021 Winter Surge in Orange County (OC), California (CA)

Background OC is the 6th largest U.S. county with 70 NHs. Universal decolonization (chlorhexidine for routine bathing, and twice daily nasal iodophor Mon-Fri every other week) was adopted in 24 NHs prior to the COVID-19 pandemic, and 12 NHs (11 of those adopting decolonization) participated in a COVID prevention training program with a rolling launch from July-Sept 2020. We evaluated the impact of these initiatives on staff and resident COVID cases. Methods We conducted a quasi-experimental study of the impact of decolonization and COVID prevention training on staff and resident COVID cases during the CA winter surge (11/16/20-1/31/21), when compared to non-participating NHs. Decolonization NHs received weekly visits for encouraging adherence during the pandemic, and NHs in the COVID training program received 3 in-person training sessions for all work shifts plus weekly feedback about adherence to hand hygiene, masking, and breakroom safety using video monitoring. We calculated incident 1) staff COVID cases, 2) resident COVID cases, and 3) resident COVID deaths adjusting for NH average daily census. We assessed impact of initiatives on these outcomes using linear mixed effects models testing the interaction between any training participation and calendar date when clustering by NH. Because of the overlap of the two initiatives, we evaluated ‘any training’ vs ‘no training.’ Results 63 NHs had available data. 24 adopted universal decolonization, 12 received COVID training (11 of which participated in decolonization), and 38 were not enrolled in either. During the winter surge, the 63 NHs experienced 1867 staff COVID cases, 2186 resident COVID cases, and 251 resident deaths due to COVID, corresponding to 29.6, 34.7, and 4.0 events per NH, respectively. In NHs participating in either initiative, staff COVID cases were reduced by 31% (OR=0.69 (0.52, 0.92), P=0.01), resident COVID cases were reduced by 43% (OR=0.57 (0.39, 0.82), P=0.003), and resident deaths were reduced (non-significantly) by 26% (OR=0.74 (0.46, 1.21), P=0.23). The grey box represents the California COVID-19 winter surge (11/16/20-1/31/21). Incident and cumulative COVID-19 cases and deaths for each nursing home were divided by the nursing home’s average daily census and multiplied by 100, representing events per 100 beds, which were aggregated across groups. Conclusion NHs are vulnerable to COVID-19 outbreaks. A universal decolonization and COVID prevention training initiative in OC, CA significantly reduced staff and resident COVID cases in this high-risk care setting. Disclosures Gabrielle Gussin, MS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products)Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products) Raveena Singh, MA, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products)Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products) Shruti K. Gohil, MD, MPH, Medline (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Molnycke (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Co-Investigator in studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Raheeb Saavedra, AS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products)Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic products) Robert Pedroza, BS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Chase Berman, BS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Susan S. Huang, MD, MPH, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)

337. SARS-CoV-2 Viral Load Does Not Predict Incident Venous Thromboembolism in COVID-19

Background The risk factors of venous thromboembolism (VTE) in COVID-19 warrant further study. We leveraged a cohort in the Military Health System (MHS) to identify clinical and virological predictors of incident deep venous thrombosis (DVT), pulmonary embolism (PE), and other VTE within 90-days after COVID-19 onset. Methods PCR or serologically-confirmed SARS-CoV-2 infected MHS beneficiaries were enrolled via nine military treatment facilities (MTF) through April 2021. Case characteristics were derived from interview and review of the electronic medical record (EMR) through one-year follow-up in outpatients and inpatients. qPCR was performed on upper respiratory swab specimens collected post-enrollment to estimate SARS-CoV-2 viral load. The frequency of incident DVT, PE, or other VTE by 90-days post-COVID-19 onset were ascertained by ICD-10 code. Correlates of 90-day VTE were determined through multivariate logistic regression, including age and sampling-time-adjusted log10-SARS-CoV-2 GE/reaction as a priori predictors in addition to other demographic and clinical covariates which were selected through stepwise regression. Results 1473 participants with SARS-CoV-2 infection were enrolled through April 2021. 21% of study participants were inpatients; the mean age was 41 years (SD = 17.0 years). The median Charlson Comorbidity Index score was 0 (IQR = 0 - 1, range = 0 - 13). 27 (1.8%) had a prior history of VTE. Mean maximum viral load observed was 1.65 x 107 genome equivalents/reaction. 36 (2.4%) of all SARS-CoV-2 cases (including inpatients and outpatients), 29 (9.5%) of COVID-19 inpatients, and 7 (0.6%) of outpatients received an ICD-10 diagnosis of any VTE within 90 days after COVID-19 onset. Logistic regression identified hospitalization (aOR = 11.1, p = 0.003) and prior VTE (aOR = 6.2 , p = 0.009) as independent predictors of VTE within 90 days of symptom onset. Neither age (aOR = 1.0, p = 0.50), other demographic covariates, other comorbidities, nor SARS-CoV-2 viral load (aOR = 1.1, p = 0.60) were associated with 90-day VTE. Conclusion VTE was relatively frequent in this MHS cohort. SARS-CoV-2 viral load did not increase the odds of 90-day VTE. Rather, being hospitalized for SARS-CoV-2 and prior VTE history remained the strongest predictors of this complication. Disclosures Simon Pollett, MBBS, Astra Zeneca (Other Financial or Material Support, HJF, in support of USU IDCRP, funded under a CRADA to augment the conduct of an unrelated Phase III COVID-19 vaccine trial sponsored by AstraZeneca as part of USG response (unrelated work)) Ryan C. Maves, MD, EMD Serono (Advisor or Review Panel member)Heron Therapeutics (Advisor or Review Panel member) David A. Lindholm, MD, American Board of Internal Medicine (Individual(s) Involved: Self): Member of Auxiliary R&D Infectious Disease Item-Writer Task Force. No financial support received. No exam questions will be disclosed ., Other Financial or Material Support David Tribble, M.D., DrPH, Astra Zeneca (Other Financial or Material Support, HJF, in support of USU IDCRP, funded under a CRADA to augment the conduct of an unrelated Phase III COVID-19 vaccine trial sponsored by AstraZeneca as part of USG response (unrelated work))

1198. Lyme Disease Post-Exposure Prophylaxis by Single-Dose Doxycycline in Three Healthcare Systems

Background Lyme disease, the most common tickborne disease in the United States, may be prevented by taking a single 200-mg dose of oral doxycycline after a high-risk bite from a blacklegged tick. Currently, it is not known how Lyme disease post-exposure prophylaxis (PEP) might vary by region and healthcare system. We identified single-dose doxycycline medication orders in three healthcare systems in states with high incidence of Lyme disease and compared associated patient and provider characteristics. Methods Electronic health record data during 2012 – 2016 were obtained from three healthcare systems: Geisinger (Pennsylvania), Marshfield Clinic (Wisconsin), and Mayo Clinic (Minnesota/Wisconsin). Creation of analytic variables and analysis were harmonized across the three sites. Medication orders for single-dose doxycycline ≤200 mg that were accompanied by specific key words or diagnostic codes (e.g., tick bite; Lyme disease prevention) were considered evidence of PEP. Manual chart review was performed from a random subset to evaluate the algorithms used to identify PEP. Results Among 2,937,585 patients with at least one medication order or clinical encounter during the study period, 14,102 single-dose doxycycline orders for Lyme disease PEP for 13,172 unique patients were identified. The typical patient receiving PEP was older (mean age 51 – 58 years), male (56 – 59%), and non-Hispanic White (81 – 98%). The annual seasonality of medication orders was bimodal, with peaks occurring during April – July and October – November. The most common encounter setting was an outpatient clinic or urgent care center (80 – 91%); medication orders after patient phone calls in the absence of an in-person visit occurred frequently (14 – 19%) in two health systems. Chart abstractions (n=600) revealed instances of PEP prescribed inappropriately (e.g., bite from a non-blacklegged tick; patient with symptoms of acute Lyme disease). Conclusion Lyme disease PEP with a single dose of doxycycline was frequently prescribed in healthcare systems where there is a high incidence of Lyme disease. PEP was most commonly prescribed to non-Hispanic Whites over the age of 50 years. Public health initiatives for tickborne disease prevention should include clinician education on the appropriate use of Lyme disease PEP. Disclosures Anna M. Schotthoefer, PhD, HelixBind (Other Financial or Material Support, salary support) John Zeuli, PharmD, INSMED (Other Financial or Material Support, honoraria for educational speaking)

11. Electronic Surveillance Criteria for Non-Ventilator HAP: Empiric testing and Chart Review at Veterans Affairs Facilities

Background Surveillance of Non-Ventilator Hospital-Acquired Pneumonia (NV-HAP) is limited by the ambiguity in diagnosing pneumonia. We implemented electronic surveillance criteria for NV-HAP across the VA healthcare system and tested for reliability, validity and meaning of the electronic criteria vs manual chart review. Methods We defined NV-HAP surveillance criteria as oxygen deterioration concurrent with fever or abnormal WBC count, ≥3 days of antibiotics, and orders for chest imaging. We applied these criteria to EHR data from all patients hospitalized ≥3 days at all VA acute care facilities from 1/1/2015-12/31/2020 and calculated NV-HAP incidence and inpatient mortality. Clinician reviewers used a consensus review guide to independently review and adjudicate 47 cases meeting NV-HAP surveillance criteria for 1) clinical deterioration, 2) CDC-NHSN pneumonia criteria, 3) treating clinicians’ assessment, and 4) reviewer’s diagnosis. All reviewers subsequently adjudicated all cases and conducted an error analysis to identify sources of discordance. Results Among 2.3M hospitalizations, 14,023 met NV-HAP surveillance criteria (0.6 per 100 admissions). Inpatient mortality was 26% (vs 2% for non-flagged hospitalizations). Among 47 hospitalizations flagged by surveillance criteria, 45 (97%) had a confirmed clinical deterioration, (the other 2 were immediate post-operative cases), 20 (43%) met CDC-NHSN pneumonia criteria, 21 (47%) had possible pneumonia per treating clinicians, and 25 (53%) had possible or probable NV-HAP per reviewers. Agreement among the 3 reviewers before adjudication was 51% (Fleiss’ κ 0.43) for CDC-NHSN and 58% (Fleiss’ κ 0.33) for NV-HAP. The most common source of discordance between reviewers was chest imaging classification (15/19 discordant cases). Conclusion NV-HAP electronic surveillance criteria demonstrated high precision for identifying clinical deterioration and moderate concordance with CDC-NHSN pneumonia criteria or reviewer diagnosis. Agreement between electronic surveillance criteria vs manual chart review was low but similar to agreement amongst manual reviewers applying NHSN criteria. Electronic surveillance may provide greater consistency than human review while facilitating wide-scale automated surveillance. Disclosures Chanu Rhee, MD, MPH, UpToDate (Other Financial or Material Support, Chapter Author) Michael Klompas, MD, MPH, UpToDate (Other Financial or Material Support, Chapter Author)