The safety of COVID-19 vaccination in immunocompromised children and young adults with immune-mediated inflammatory disease.

AIM: To assess safety of COVID-19 vaccination in paediatric patients with immune-mediated inflammatory disease (IMID). METHODS: Subjects of 5-21 years of age with IMID who received at least one COVID-19 vaccine completed electronic surveys after each vaccine to assess side effects within 1 week of vaccination, current medications and COVID-19 testing after vaccination. Charts were reviewed for COVID-19 polymerase chain reaction and IgG response to SARS-CoV-2 spike protein results and for disease flare during the study period. RESULTS: Among 190 enrolled subjects, 71% were female, with median age 17 (range 6-21) years. The most common diagnosis was juvenile idiopathic arthritis/rheumatoid arthritis (55%). 78% of subjects were taking immunosuppressive medication. At least one side effect was reported in 65% of subjects after any dose of the vaccine; with side effects in 38%, 53% and 55% of subjects after the first, second and third vaccine doses, respectively. The most common side effects were injection site pain (59%), fatigue (54%) and headache (39%). No anaphylaxis or myocarditis was reported. Three subjects (2%) experienced disease flare. CONCLUSION: In our cohort of paediatric patients with IMID, observed side effects were found to be mild and disease flare rates were found to be low following COVID-19 vaccination.

Feasibility of Onboarding and Supporting Diabetes Technologies in Youth with Type 1 Diabetes during the COVID-19 Pandemic and Beyond

Background: Prior to COVID-19 lockdown, all new insulin pump training was done in house with the patient and families in attendance. However, the pandemic lockdown made it difficult for in-person education. Therefore, we embarked on virtual trainings as well as in-person training for new insulin pump starts. Aim: To evaluate the feasibility and effectiveness of remote and in-person trainings by comparing management metrics in the years of 2020 and 2021. Methods: We compared the age, race, sex, glycemic control at 6 months post insulin pump initiation, incidence of severe hypoglycemic episodes, and diabetic ketoacidosis (DKA) among the two training models. Results: There were 118 insulin pump starts during the study period, of which 73 (62%) were in-person: (49 (67%) male, mean ± SD age was 10.6 ± 4.0 years, and 40 (55%) White, 11 (15%) Black and 22 (30%) other;and 39 (33%) were remote: (19 (49%) male, mean ± SD age: 11.6 ± 4.0 years, and 26 (67%) White, 4 (10%) Black, and 9 (23%) other race. There were no cases of severe hypoglycemia requiring a third-party assistance, hospitalizations, or DKA in the first 6 months after insulin pump initiation in either group. The proportion of subjects with optimal glycemic control (A1c of ≤7%) at 6 months following pump initiation was similar between the two training groups after adjusting for baseline A1c and BMI percentile group (p=0.35) . Conclusion: This study found no evidence that remote pump training was less safe than in-person training. Therefore, remote training could be an alternative method to promote health equity by increasing access to diabetes technology for youth with type 1 diabetes in whom in-person training may be a challenge. A larger study is warranted to further evaluate the safety and effectiveness of this alternative method.

The Effect of the COVID-19 Pandemic on Pediatric Physician Wellness: A Cross-Sectional Study.

The COVID-19 pandemic has provided challenges to all healthcare workers. While the brunt of treating COVID-19 patients fell upon adult providers, pediatricians also experienced significant stressors and disruptions. Academic pediatricians and trainees (fellows and residents) were redeployed to manage adult patients in hospitalist and intensive care settings and/or had major changes to their clinical schedules. In this study, we aimed to describe levels of self-reported depression, anxiety, and burnout in pediatric physicians following the initial wave of the pandemic at the largest integrated health system in New York State. A cross-sectional study was conducted among pediatric physicians who cared for patients during the COVID-19 pandemic within the Northwell Health System as part of the Northwell Wellbeing Registry, a longitudinal registry assessing the psychological impact of COVID-19 on healthcare providers. A total of 99 pediatric physician respondents were included in this study; 72% of whom were attendings, 28% of whom were trainees. Compared to attendings, trainees reported significantly higher proportions of burnout-emotional exhaustion (p = 0.0007) and burnout-depersonalization (p = 0.0011) on the Abbreviated Maslach Burnout Inventory. There was not a similar trend in probable depression or probable anxiety using the Patient Health Questionnaire. In a multivariable logistic regression model, being a trainee was significantly associated with increased odds of burnout-emotional exhaustion (OR 5.94, 95% Confidence Interval: 1.85-19.02). These findings suggest that fellows and residents were a vulnerable population during the COVID-19 pandemic. Training programs should pay special attention to their trainees during times of crisis, and future studies can help to identify protective factors to reduce the risk of burnout during these times.

Delayed cardiac repolarisation as a predictor of in-hospital mortality in patients with COVID-19.

OBJECTIVE: With the rapid influx of COVID-19 admissions during the first wave of the pandemic, there was an obvious need for an efficient and streamlined risk stratification tool to aid in triaging. To this date, no clinical prediction tool exists for patients presenting to the hospital with COVID-19 infection. METHODS: This is a retrospective cohort study of patients admitted in one of 13 Northwell Health Hospitals, located in the wider New York Metropolitan area between 1 March 2020 and 27 April 2020. Inclusion criteria were a positive SARS-CoV-2 nasal swab, a 12-lead ECG within 48 hours, and a complete basic metabolic panel within 96 hours of presentation. RESULTS: All-cause, in-hospital mortality was 27.1% among 7098 patients. Independent predictors of mortality included demographic characteristics (male gender, race and increased age), presenting vitals (oxygen saturation <92% and heart rate >120 bpm), metabolic panel values (serum lactate >2.0 mmol/L, sodium >145, mmol/L, blood urea nitrogen >40 mmol/L, aspartate aminotransferase >40 U/L, Creatinine >1.3 mg/dL and glycose >100 mg/L) and comorbidities (congestive heart failure, chronic obstructive pulmonary disease and coronary artery disease). In addition to those, our analysis showed that delayed cardiac repolarisation (QT corrected for heart rate (QTc) >500 ms) was independently associated with mortality (OR 1.41, 95% CI 1.05 to 1.90). Previously mentioned parameters were incorporated into a risk score that accurately predicted in-hospital mortality (AUC 0.78). CONCLUSION: In the largest cohort of COVID-19 patients with complete ECG data on presentation, we found that in addition to demographics, presenting vitals, clinical history and basic metabolic panel values, QTc >500 ms is an independent risk factor for in-hospital mortality.

Atrial fibrillation is an independent predictor for in-hospital mortality in patients admitted with SARS-CoV-2 infection.

BACKGROUND: Atrial fibrillation (AF) is the most encountered arrhythmia and has been associated with worse in-hospital outcomes. OBJECTIVE: This study was to determine the incidence of AF in patients hospitalized with coronavirus disease 2019 (COVID-19) as well as its impact on in-hospital mortality. METHODS: Patients hospitalized with a positive COVID-19 polymerase chain reaction test between March 1 and April 27, 2020, were identified from the common medical record system of 13 Northwell Health hospitals. Natural language processing search algorithms were used to identify and classify AF. Patients were classified as having AF or not. AF was further classified as new-onset AF vs history of AF. RESULTS: AF occurred in 1687 of 9564 patients (17.6%). Of those, 1109 patients (65.7%) had new-onset AF. Propensity score matching of 1238 pairs of patients with AF and without AF showed higher in-hospital mortality in the AF group (54.3% vs 37.2%; P < .0001). Within the AF group, propensity score matching of 500 pairs showed higher in-hospital mortality in patients with new-onset AF as compared with those with a history of AF (55.2% vs 46.8%; P = .009). The risk ratio of in-hospital mortality for new-onset AF in patients with sinus rhythm was 1.56 (95% confidence interval 1.42-1.71; P < .0001). The presence of cardiac disease was not associated with a higher risk of in-hospital mortality in patients with AF (P = .1). CONCLUSION: In patients hospitalized with COVID-19, 17.6% experienced AF. AF, particularly new-onset, was an independent predictor of in-hospital mortality.

Safely Administering Potential QTc Prolonging Therapy Across a Large Health Care System in the COVID-19 Era.

BACKGROUND: The severe acute respiratory syndrome coronavirus 2 (SARs-CoV-2) has resulted in a global pandemic. Hydroxychloroquine±azithromycin have been widely used to treat coronavirus disease 2019 (COVID-19) despite a paucity of evidence regarding efficacy. The incidence of torsade de pointes remains unknown. Widespread use of these medications forced overwhelmed health care systems to search for ways to effectively monitor these patients while simultaneously trying to minimize health care provider exposure and use of personal protective equipment. METHODS: Patients with COVID-19 positive who received hydroxychloroquine±azithromycin across 13 hospitals between March 1 and April 15 were included in this study. A comprehensive search of the electronic medical records was performed using a proprietary python script to identify any mention of QT prolongation, ventricular tachy-arrhythmias and cardiac arrest. RESULTS: The primary outcome of torsade de pointes was observed in 1 (0.015%) out of 6476 hospitalized patients with COVID-19 receiving hydroxychloroquine±azithromycin. Sixty-seven (1.03%) had hydroxychloroquine±azithromycin held or discontinued due to an average QT prolongation of 60.5±40.5 ms from a baseline QTc of 473.7±35.9 ms to a peak QTc of 532.6±31.6 ms. Of these patients, hydroxychloroquine±azithromycin were discontinued in 58 patients (86.6%), while one or more doses of therapy were held in the remaining nine (13.4%). A simplified approach to monitoring for QT prolongation and arrythmia was implemented on April 5. There were no deaths related to the medications with the simplified monitoring approach and health care provider exposure was reduced. CONCLUSIONS: The risk of torsade de pointes is low in hospitalized patients with COVID-19 receiving hydroxychloroquine±azithromycin therapy.

Early Experience of COVID-19 in a US Children's Hospital.

OBJECTIVES: We aim to describe the demographics, clinical presentation, hospital course, and severity of pediatric inpatients with coronavirus disease 2019 (COVID-19), with an emphasis on healthy, immunocompromised, and chronically ill children. METHODS: We conducted a single-center retrospective cohort study of hospitalized children aged younger than 22 years with COVID-19 infection at Steven and Alexandra Cohen Children's Medical Center at Northwell Health. Cases were identified from patients with fever and/or respiratory symptoms who underwent a nucleic acid amplification-based test for severe acute respiratory syndrome coronavirus 2. RESULTS: Sixty-five patients were identified. The median age was 10.3 years (interquartile range, 1.4 months to 16.3 years), with 48% of patients older than 12 years and 29% of patients younger than 60 days of age. Fever was present in 86% of patients, lower respiratory symptoms or signs in 60%, and gastrointestinal symptoms in 62%. Thirty-five percent of patients required ICU care. The white blood cell count was elevated in severe disease (P = .0027), as was the C-reactive protein level (P = .0192), compared with mild and moderate disease. Respiratory support was required in 34% of patients. Severity was lowest in infants younger than 60 days of age and highest in chronically ill children; 79% of immunocompromised children had mild disease. One death was reported. CONCLUSIONS: Among children who are hospitalized for COVID-19, most are younger than 60 days or older than 12 years of age. Children may have severe infection requiring intensive care support. The clinical course of immunocompromised patients was not more severe than that of other children. Elevated white blood cell count and C-reactive protein level are associated with greater illness severity.