Background The gut microbiome impacts the efficacy of immune checkpoint inhibitor (ICI) therapy and the development of ICI-mediated diarrhea and / or colitis (IMDC). Antibiotic therapy,especially that with anaerobic activity, has profound effects on the gut microbiome. Therefore, we sought to assess the effect of antibiotics on the development of IMDC. Methods Patients who received ICI therapy from January 2016 to January 2018 were examined retrospectively. A Cox regression model was used to assess factors associated with overall survival. Results A total of 826 patients were included. Of these patients, 51.6% received inhibitors of programmed cell death protein-1 or its ligand, 32.0% received inhibitors of cytotoxic T-lymphocyte-associated antigen-4, and 16.5% received a combination of the two. IMDC occurred in 52.5% of the patients after a median of 8 weeks. Overall, 569 patients (68.9%) received antibiotic therapy. Antibiotic use at any time was associated with reduced IMDC occurrence and recurrence rates but also with frequent hospitalization and intensive care unit admission for IMDC as well as increased IMDC severity. Compared with patients who received antibiotic therapy only before ICI therapy initiation, those receiving it after ICI had a higher IMDC rate and more often needed immunosuppressive therapy and hospitalization for IMDC. Antibiotics with anaerobic activity were included in 51% of the antibiotic therapy regimens and were associated with increased immunosuppressant use, hospitalization, intensive care unit admission for IMDC, and severe IMDC grades. Forty-one patients received empiric prophylactic antibiotic therapy at IMDC onset. These patients more often needed immunosuppressive therapy, intravenous steroids, and infliximab/vedolizumab; had more frequent and longer hospitalization for IMDC and higher IMDC grades; and more frequently had IMDC recurrence than did patients who did not receive antibiotic therapy at the time of IMDC symptom onset. Conclusions Whereas antibiotic therapy appeared to be protective against IMDC onset, use of antibiotics, especially those with anaerobic activity, after ICI therapy was associated with increased risk of severe IMDC. Electronic supplementary material The online version of this article (10.1186/s40425-019-0714-x) contains supplementary material, which is available to authorized users.

OBJECTIVE Older adults, those aged 65 and older, frequently require emergency care. However, only limited national data describe the Emergency Medical Services (EMS) care provided to older adults. We sought to determine the characteristics of EMS care provide to older adults in the United States. METHODS We used data from the 2014 National Emergency Medical Services Information System (NEMSIS), encompassing EMS response data from 46 States and territories. We excluded EMS responses for children <18 years, interfacility transports, intercepts, non-emergency medical transports and standby responses. We defined older adults as age ≥65 years. We compared patient demographics (age, sex, race, primary payer), response characteristics (dispatch time, location type, time intervals) and clinical course (clinical impression, injury, procedures, medications) between older and younger adult EMS emergency “911” responses. RESULTS During the study period there were 20,212,245 EMS emergency responses. Among the 16,116,219 adult EMS responses, there were 6,569,064 (40.76%) older and 9,547,155 (59.24%) younger adults. Older EMS patients were more likely to be white and the EMS incident to be located in healthcare facilities (clinic, hospital, nursing home). Compared with younger patients, older EMS patients were more likely to present with syncope (5.68% vs. 3.40%; OR 1.71; CI: 1.71–1.72), cardiac arrest/rhythm disturbance (3.27% vs. 1.69%; OR 1.97; CI: 1.96–1.98), stroke (2.18% vs. 0.74%; OR 2.99; CI: 2.96–3.02) and shock (0.77% vs. 0.38%; OR 2.02; CI: 2.00–2.04). Common EMS interventions performed on older persons included intravenous access (32.02%), 12-lead ECG (14.37%), CPR (0.87%) and intubation (2.00%). The most common EMS drugs administered to older persons included epinephrine, atropine, furosemide, amiodarone, and albuterol or ipratropium. CONCLUSION One of every three US EMS emergency responses involves older adults. EMS personnel must be prepared to care for the older patient.

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WHAT DEFINES AN HONORS 3 RD YEAR MEDICAL STUDENT DURING HOSPITAL WARDS? ACGME CORE COMPETENCIES How much emphasis do you place on each of the following characteristics when designating a student as "honors" (or the highest grade)? Circle a number Patient Care (PC): Provides patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health 1= less emphasis

Gastrointestinal parasites are generally associated with lower-income countries in tropical and subtropical areas, but they are also prevalent in low-income and extreme low-income communities in the Southern United States. To date, studies characterizing the epidemiology of gastrointestinal parasites in the United States are limited, resulting in little comprehensive understanding of the challenge. This study investigates the environmental contamination of gastrointestinal parasites in the Southern United States by determining the contamination rate and burden of each parasite in five low-income communities. A total of 499 soil samples of approximately 50g were collected from public parks and private residences in Alabama, Louisiana, Mississippi, South Carolina, and Texas. A novel technique utilizing parasite floatation, filtration, and bead-beating was applied to concentrate and extract parasite DNA from samples. A multi-parallel qPCR-based molecular method detected Blastocystis spp (19.0%), Toxocara cati (6.01%), Toxocara canis (3.61%), Strongyloides stercoralis (2.00%), Trichuris trichiura (1.80%), Ancylostoma duodenale (1.42%), Giardia intestinalis (1.40%), Cryptosporidium spp (1.00%), Entamoeba histolytica (0.201%), and Necator americanus (0.200%). Overall parasite contamination rates varied significantly between communities: Western Mississippi (46.88%); Southwestern Alabama (39.62%); Northeastern Louisiana (28.24%); Southwestern South Carolina (27.03%); and South Texas (6.93%) (p < 0.0001). Furthermore, Toxocara spp. contamination rates were correlated with community poverty rates (rs = 0.7000; p = 0.2333). Toxocara cati DNA burdens were greater in communities with higher poverty rates, including Northeastern Louisiana (50.57%) and Western Mississippi (49.60%) compared to Southwestern Alabama (30.05%) (p = 0.0011). This study demonstrates the environmental contamination of parasites and their relationship with high poverty rates in communities in the Southern United States.

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Background We hypothesized that we could leverage social media to recruit learners to a gamification-infused ID knowledge competition, and entice them to explore additional online educational resources. Methods We created the ID Fellows Cup, a knowledge-based trivia competition, to engage Infectious Diseases fellows. The game was crafted via Kaizen-Education, a software platform developed at the University of Alabama at Birmingham, that uses gamification to engage learners. Multiple choice questions including figures and/or text are presented to learners, followed by detailed teaching explanations. 60 questions emphasizing high-yield concepts were delivered over 4 weeks. Questions were written by fellows and reviewed by faculty at three programs. Elements of gamification (virtual rewards, leaderboards, etc.) were included to enhance engagement. Recruitment strategies included Twitter, program director emails, and peer-to-peer. We measured game statistics and participation. Learners were invited to complete a post-game survey about their experience. Results Table 1 shows our game statistics with broad geographic reach including 42 programs. Most fellows matriculated in 2019 or 2020; the number of US ID fellows equaled 17% of those completing ID in-training exam. Recruitment sources included 44% co-fellow, 42% Twitter, and 15% Program Director. Through 20 days with questions, we had 155 daily average users. Overall, fellows answered 11,419 total questions, representing 89% of all released questions. Of 103 responses to post-game survey (table 2) 97% would participate again and all felt the game was a good use of their time. Over 80% of participants reported some engagement with linked resources included in the answer explanations. In general, 78% felt engagement with online resources increased subsequent to participating in the game, including learning about at least one new online resource. Conclusion We leveraged social media and gamification to effectively engage, and stimulate ID learners to explore additional online educational resources. Technology enriched learning, helps supplement and globalize ID education, making it as diverse and engaging as our field. Disclosures Todd P. McCarty, MD, Cidara (Grant/Research Support)GenMark (Grant/Research Support, Other Financial or Material Support, Honoraria for Research Presentation)T2 Biosystems (Consultant) Prathit A. Kulkarni, M.D., Vessel Health, Inc. (Grant/Research Support)