Multi-omic longitudinal study reveals immune correlates of clinical course among hospitalized COVID-19 patients.

The IMPACC cohort, composed of >1,000 hospitalized COVID-19 participants, contains five illness trajectory groups (TGs) during acute infection (first 28 days), ranging from milder (TG1-3) to more severe disease course (TG4) and death (TG5). Here, we report deep immunophenotyping, profiling of >15,000 longitudinal blood and nasal samples from 540 participants of the IMPACC cohort, using 14 distinct assays. These unbiased analyses identify cellular and molecular signatures present within 72 h of hospital admission that distinguish moderate from severe and fatal COVID-19 disease. Importantly, cellular and molecular states also distinguish participants with more severe disease that recover or stabilize within 28 days from those that progress to fatal outcomes (TG4 vs. TG5). Furthermore, our longitudinal design reveals that these biologic states display distinct temporal patterns associated with clinical outcomes. Characterizing host immune responses in relation to heterogeneity in disease course may inform clinical prognosis and opportunities for intervention.

Volume and Severity of Pediatric COVID-19 Hospitalizations in the United States.

OBJECTIVES: Using administrative data from pediatric hospitals in the United States, we examined trends in coronavirus disease 2019 (COVID-19) hospitalizations and severity of disease among children. METHODS: We extracted data from the Pediatric Health Information System for hospitalized patients less than 12 years old with COVID-19 (identified by primary or secondary International Classification of Diseases-10 diagnosis code U07.1) admitted from April 2020 to August 2022. We examined weekly trends in COVID hospitalization volume overall and by ICU utilization as a measure of severe disease and by COVID diagnosis hierarchy (primary versus secondary) as a proxy for incidental admissions. We estimated the annualized trend in the ratio of hospitalizations requiring, versus not requiring, ICU care and the trend in ratio of hospitalizations with a primary versus secondary COVID diagnosis. RESULTS: We included 38 160 hospitalizations across 45 hospitals. Median age was 2.4 years (interquartile range = 0.7-6.6). Median length of stay was 2.0 days (interquartile range = 1-4). ICU-level care was required for 18.9% and 53.8% had a primary diagnosis of COVID-19. The ratio of ICU to non-ICU admissions declined by 14.5% annually (95% confidence interval: -21.7% to -7.26%; P < .001), whereas the ratio of primary to secondary diagnosis was stable (11.7% annually; 95% confidence interval: -8.83% to 32.4%; P = .26). CONCLUSIONS: Periodic increases in pediatric COVID-19 hospitalizations with are evident. However, there is no evidence of corresponding increase in severity of illness that may provide context for recent reports of increasing pediatric COVID hospitalizations in addition to health policy implications.

Telemedicine for Adolescent and Young Adult Long-Acting Reversible Contraception Follow-Up Care amidst a Global Pandemic.

STUDY OBJECTIVE: To describe adolescent and young adult (AYA) long-acting reversible contraception (LARC) follow-up care via telemedicine in the year following the COVID-19 pandemic onset DESIGN: Longitudinal cohort study SETTING: Three academic adolescent medicine clinics in the United States PARTICIPANTS: AYAs using LARC INTERVENTIONS: None MAIN OUTCOME MEASURES: The main outcome measures were patient characteristics, visit information (frequency, timing, and modality), patient-reported symptoms, and outcomes for those presenting for LARC follow-up care between April 1, 2020, and March 31, 2021. Descriptive statistics were used to describe the sample. χ2 tests and t tests were used to compare groups. Adjusted logistic regression models using general estimating equations were applied to assess factors associated with telemedicine visits and to examine visit outcomes. RESULTS: Of the 319 AYAs (ages 13.6-25.7 years), 40.1% attended at least one LARC telemedicine visit. Patients attending any telemedicine encounter vs only in-person visits had similar demographic and clinical characteristics. Of the 426 follow-up visits, 270 (63.4%) were conducted in person and 156 (36.6%) were performed via telemedicine. Most visits (62.7%) occurred within 12 months of device insertion. Reports of bothersome uterine bleeding beyond patient expectations (OR = 1.26; 95% CI, 0.80-1.96), any symptom (OR = 1.40; 95% CI, 0.94-2.10), or 2 or more symptoms (OR = 1.22; 95% CI, 0.67-2.22) at follow-up was not associated, positively or negatively, with mode of follow-up. Management of bleeding (OR = 1.27; 95% CI, 0.56-2.89), management of acne (P = .46), and need for rapid follow-up (P = .33) were similar between follow-up modalities. CONCLUSIONS: Patient demographic/clinical characteristics and visit outcomes were similar between telemedicine and in-person LARC follow-up. Telemedicine could play an important role in AYA LARC care.

COVID-19 related familial economic disruptions and eating disorder patients' mental health concerns and motivation to recover.

BACKGROUND: Family support has been shown to be important for adolescents and young adults (AYA) in eating disorder (ED) treatment. Many families were impacted by the pandemic, potentially altering their ability to support individuals in ED treatment. This study examined the association of COVID-19 related familial economic change with self-reported mental health (MH) and ED concerns in AYA seeking treatment for ED. METHODS: AYA patients with EDs aged 10-27 years enrolled in the Registry of Eating Disorders and their Co-morbidities OVER time in Youth (RECOVERY) completed an additional COVID-19-specific survey (n = 89) that assessed their perception of the effects of the pandemic on their lives and their ED. Participants self-reported on familial economic disruptions, measured through a composite score of four markers: (1) family member's work hours cut, (2) family member was required to stop working, (3) family member lost job permanently, and (4) family lost health insurance/benefits. In bivariate analyses, we examined the association between self-reporting any familial economic disruption and self-reported changes in intrusive ED thoughts, feelings of anxiety, feelings of depression, feelings of isolation, and motivation to recover from their ED. Logistic regression models were used to examine the association between familial economic disruptions on self-reported changes in ED/MH affect and motivation to recover adjusting for age and ED diagnosis. RESULTS: Forty-six percent of participants self-reported that the pandemic had resulted in at least one economic familial disruption. Of patients reporting any familial economic disruption, 29% reported decreased motivation for ED recovery, and over 75% reported worsening feelings of depression, anxiety, isolation, and/or intrusive eating disorder thoughts. Reporting any COVID-19 familial economic disruption was marginally associated with feelings of isolation (p = 0.05). Though the findings were only marginally significant, the odds of reporting worsening feelings of depression, anxiety, intrusive ED thoughts or motivation to recover were nearly twice in those who reported a COVID-19-related familial economic disruption compared to those who did not report such a disruption. CONCLUSIONS: Family-related economic disruptions are associated with ED/MH-related concerns and motivation to recover from an ED during the COVID-19 pandemic in AYA patients.

Following the adoption of stay-at-home regulations to curb the spread of the COVID-19 pandemic, children's hospitals and emergency rooms across the United States saw a tremendous uptick in adolescents and young adults with eating disorders (ED) and mental health (MH) concerns. COVID-19 related regulations had economic consequences, with family members reduction in work hours, temporary or permanent termination from work, and/or loss of their health insurance or benefits. This study sheds light on the association between COVID-19 related familial economic disruptions and mental health and eating disorders (MH/ED) concerns and motivation to recover from an ED in patients receiving care for ED (89 participants). Of patients reporting some economic familial disruption, three-fourths self-reported worsening mental health (i.e, worsening feelings of depression, anxiety, isolation, or intrusive eating disorder thoughts). Patients who perceived familial economic disruption due to the COVID-19 pandemic had almost a two-fold increased likelihood of worsening eating disorders and mental health (ED/MH) concerns and/or motivation to recover. Our study underscores the need to consider the economic effects of the pandemic on the well-being of adolescents/young-adults with ED, particularly those from financially vulnerable families.

Emergency Department Visits and Hospitalizations for Eating Disorders During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Recent studies have reported increasing eating disorder incidence and severity following the coronavirus disease 2019 (COVID-19) pandemic. In a diverse cohort of pediatric hospitals, we examined trends in the volume of emergency visits and inpatient admissions for eating disorders before and during the pandemic. METHODS: We examined monthly trends in volume of patients with eating disorders (identified by principal International Classification of Diseases, 10th Revision, diagnosis codes) across 38 hospitals in the Pediatric Health Information System pre- (January 2018-March 2020) and post-COVID-19 onset (April 2020-June 2022). Using interrupted time series analysis, we examined the pre- and post monthly trends in eating disorder emergency and inpatient volume. RESULTS: Before the pandemic, eating disorder emergency visit volume was increasing by 1.50 visits per month (P = .006), whereas in the first year postonset, visits increased by 12.9 per month (P < .001), followed by a 6.3 per month decrease in the second year postonset (P < .001). Pre-COVID-19, eating disorder inpatient volume was increasing by 1.70 admissions per month (P = .01). In the first year postonset, inpatient volume increased by 11.9 per month (P < .001), followed by a 7.6 per month decrease in the second year postonset (P < .001). CONCLUSIONS: The volume of patients seeking emergency and inpatient eating disorder care at pediatric hospitals has increased dramatically since the pandemic onset and has not returned to prepandemic levels despite a decline in the second year postonset, with important implications for hospital capacity.

Association of the COVID-19 Pandemic With Adolescent and Young Adult Eating Disorder Care Volume.

Importance: The COVID-19 pandemic has affected youth mental health. Increases in site-specific eating disorder (ED) care have been documented; however, multisite studies demonstrating national trends are lacking. Objective: To compare the number of adolescent/young adult patients seeking inpatient and outpatient ED care before and after onset of the COVID-19 pandemic. Design, Setting, and Participants: Using an observational case series design, changes in volume in inpatient and outpatient ED-related care across 15 member sites (14 geographically diverse hospital-based adolescent medicine programs and 1 nonhospital-based ED program) of the US National Eating Disorder Quality Improvement Collaborative was examined. Sites reported monthly volumes of patients seeking inpatient and outpatient ED care between January 2018 and December 2021. Patient volumes pre- and postpandemic onset were compared separately for inpatient and outpatient settings. Demographic data such as race and ethnicity were not collected because this study used monthly summary data. Exposures: Onset of the COVID-19 pandemic. Main Outcomes and Measures: Monthly number of patients seeking inpatient/outpatient ED-related care. Results: Aggregate total inpatient ED admissions were 81 in January 2018 and 109 in February 2020. Aggregate total new outpatient assessments were 195 in January 2018 and 254 in February 2020. Before the COVID-19 pandemic, the relative number of pooled inpatient ED admissions were increasing over time by 0.7% per month (95% CI, 0.2%-1.3%). After onset of the pandemic, there was a significant increase in admissions over time of 7.2% per month (95% CI, 4.8%-9.7%) through April 2021, then a decrease of 3.6% per month (95% CI, -6.0% to -1.1%) through December 2021. Prepandemic, pooled data showed relative outpatient ED assessment volume was stable over time, with an immediate 39.7% decline (95% CI, -50.4% to -26.7%) in April 2020. Subsequently, new assessments increased by 8.1% (95% CI, 5.3%-11.1%) per month through April 2021, then decreased by 1.5% per month (95% CI, -3.6% to 0.7%) through December 2021. The nonhospital-based ED program did not demonstrate a significant increase in the absolute number of admissions after onset of the pandemic but did see a significant increase of 8.2 (95% CI, 6.2-10.2) additional inquiries for care per month in the first year after onset of the pandemic. Conclusions and Relevance: In this study, there was a significant COVID-19 pandemic-related increase in both inpatient and outpatient volume of patients with EDs across sites, particularly in the first year of the pandemic. Given inadequate ED care availability prior to the pandemic, the increased postpandemic demand will likely outstrip available resources. Results highlight the need to address ED workforce and program capacity issues as well as improve ED prevention strategies.

Phenotypes of disease severity in a cohort of hospitalized COVID-19 patients: Results from the IMPACC study.

BACKGROUND: Better understanding of the association between characteristics of patients hospitalized with coronavirus disease 2019 (COVID-19) and outcome is needed to further improve upon patient management. METHODS: Immunophenotyping Assessment in a COVID-19 Cohort (IMPACC) is a prospective, observational study of 1164 patients from 20 hospitals across the United States. Disease severity was assessed using a 7-point ordinal scale based on degree of respiratory illness. Patients were prospectively surveyed for 1 year after discharge for post-acute sequalae of COVID-19 (PASC) through quarterly surveys. Demographics, comorbidities, radiographic findings, clinical laboratory values, SARS-CoV-2 PCR and serology were captured over a 28-day period. Multivariable logistic regression was performed. FINDINGS: The median age was 59 years (interquartile range [IQR] 20); 711 (61%) were men; overall mortality was 14%, and 228 (20%) required invasive mechanical ventilation. Unsupervised clustering of ordinal score over time revealed distinct disease course trajectories. Risk factors associated with prolonged hospitalization or death by day 28 included age ≥ 65 years (odds ratio [OR], 2.01; 95% CI 1.28-3.17), Hispanic ethnicity (OR, 1.71; 95% CI 1.13-2.57), elevated baseline creatinine (OR 2.80; 95% CI 1.63- 4.80) or troponin (OR 1.89; 95% 1.03-3.47), baseline lymphopenia (OR 2.19; 95% CI 1.61-2.97), presence of infiltrate by chest imaging (OR 3.16; 95% CI 1.96-5.10), and high SARS-CoV2 viral load (OR 1.53; 95% CI 1.17-2.00). Fatal cases had the lowest ratio of SARS-CoV-2 antibody to viral load levels compared to other trajectories over time (p=0.001). 589 survivors (51%) completed at least one survey at follow-up with 305 (52%) having at least one symptom consistent with PASC, most commonly dyspnea (56% among symptomatic patients). Female sex was the only associated risk factor for PASC. INTERPRETATION: Integration of PCR cycle threshold, and antibody values with demographics, comorbidities, and laboratory/radiographic findings identified risk factors for 28-day outcome severity, though only female sex was associated with PASC. Longitudinal clinical phenotyping offers important insights, and provides a framework for immunophenotyping for acute and long COVID-19. FUNDING: NIH.

The Impact of the COVID-19 Pandemic on the Number of Adolescents/Young Adults Seeking Eating Disorder-Related Care.

PURPOSE: The COVID-19 pandemic has led to the development and worsening of eating disorder (ED) symptoms in adolescents and young adults. In order to examine COVID-19-related trends in ED care-seeking at our institution. METHODS: We used interrupted time series regression to examine pre- and postpandemic monthly summary data of the following: (1) ED-related inpatient admissions for medical stabilization; (2) ED-related hospital bed-days; (3) completed outpatient ED assessments; and (4) ED outpatient care-related inquiries at a children's hospital in Boston, MA. RESULTS: Inpatient admissions, hospital bed-days, and outpatient care-related inquiries increased on average over time postpandemic compared to stable volume over time prepandemic (p < .01). Outpatient assessments decreased precipitously initially following COVID-19-related limitations, and rose quickly back to baseline. CONCLUSION: These results indicate increased need for ED-related care during the pandemic. Bolstering resources to meet the needs of these vulnerable patients is critical as the effects of the pandemic continue to be felt.

COVID-19 and eating disorder and mental health concerns in patients with eating disorders.

BACKGROUND: The Coronavirus (COVID-19) pandemic dramatically transformed daily life for adolescents and young adults, altering social and physical environments. Previous research has shown such shifts in daily life to be especially challenging for people living with eating disorders (ED). However, the extent of this environmental change on ED symptoms and mental health (MH) has been relatively unexplored in patients with EDs. This study examines how young people with EDs feel the COVID-19 pandemic has affected their living environments as well as their ED and MH symptoms and motivation for ED recovery. METHODS: Participants were enrollees in the Registry of Eating Disorders and their Co-morbidities OVER time in Youth (RECOVERY) who responded to an additional survey (n = 89) in July 2020 to assess their perceptions of the impact of the COVID-19 pandemic. Participants reported on concerns of their ED worsening due to increased time living in a "triggering environment" due to the pandemic as well as perceived COVID-related changes in intrusive ED thoughts, depression, anxiety, isolation, and motivation to recover. Logistic regression models, adjusted for age and ED diagnosis, examined the association of triggering environment with ED and MH symptoms. RESULTS: The majority of respondents reported concern for worsening of their ED due to a "triggering environment" (63%). Most reported an increase in ED thoughts (74%), feelings of anxiety (77%), depression (73%), and isolation (80%) they perceived to be related to the pandemic. Nearly one-third reported decrease in motivation to recover (29%) they perceived to be related to the pandemic. After adjusting for age and ED diagnosis, participants who reported concern for worsening of their ED due to a triggering environment had nearly 18 times the odds of decreased motivation to recover (OR 18.1; 95% CI 3.37-97.4, p = 0.003) and nearly 24 times the odds of increased ED thoughts (OR 23.8; 95% CI 4.31-131.6, p < 0.001) compared to those who did not report concern for worsening of their ED due to a triggering environment. CONCLUSIONS: Our findings demonstrate the perceived negative impact the COVID-19 pandemic has had on the self-reported ED and MH symptoms in patients with EDs, particularly in those who report concern for a negative environmental change. These results underscore the need for heightened monitoring of patients with EDs during the pandemic.

The COVID-19 pandemic and subsequent stay-at-home orders implemented across the world dramatically altered daily life for people of all ages. Previous research has detailed the profound impact the pandemic has had on mental health (MH), particularly among individuals with eating disorders (ED) [22]. This study explored how individuals with eating disorders perceive the COVID-19 pandemic to have impacted their ED symptoms and overall MH. Participants included adolescent/young adults (AYAs) with a diagnosed ED who were given a four-part survey on how they perceive the COVID-19 pandemic to have affected their ED symptoms and treatment and MH (89 participants). AYAs in the study reported feeling that their ED symptoms and MH concerns worsened due to the pandemic. Those who reported concern that their ED would worsen due to a "triggering" living environment were even more likely to report feeling that their ED and MH worsened due to the pandemic. A large percentage of participants also reported a decreased motivation to recover from their ED that they attributed to the pandemic. Overall, individuals with EDs may be at risk for worsening symptoms during the COVID-19 pandemic. Our results underscore the need for increased monitoring of patients with EDs during the pandemic.

Access to care and worsening eating disorder symptomatology in youth during the COVID-19 pandemic.

BACKGROUND: Shelter-in-place orders and social distancing guidelines, in response to the COVID-19 pandemic, have limited traditional face-to-face interactions and led to many clinical providers transitioning to the use of videoconferencing platforms. The present study aims to assess how the COVID-19 pandemic has impacted adolescents'/young adults' (AYA) eating disorder (ED)-related care, and how access to, changes in, perceived disruptions to, and quality of care are associated with ED thoughts and behaviors. METHODS: AYA enrolled in the RECOVERY study, a pre-existing web-based longitudinal study, and completed a COVID-19-specific survey (n = 89). We examined bivariate associations of four markers of care: i) access to care, ii) changes in care, iii) perceived disruption to care, and iv) quality of care. Using multiple logistic regression, we examined the associations of pandemic-related markers of care with changes in ED thoughts and behaviors. We excluded those not engaged in treatment pre-pandemic (n = 16). RESULTS: In the remaining 73 participants, reported access to care was high, with 92% of respondents continuing care with at least one ED provider during the pandemic; however, 47% stopped some treatment during the pandemic. Nearly one-third (32%) perceived a disruption in treatment. Quality of care remained high with 67% reporting care to be better than or as good as pre-pandemic. Respondents acknowledged heightened symptomatology: 81% reported increased ED thoughts and 81% reported increased ED behaviors due to COVID-19-related factors. However, none of the markers of care described were significantly associated with ED thoughts or behaviors in regression analyses adjusting for demographic variables and baseline characteristics, except our quality of care measure which was approaching significance (p = 0.07). CONCLUSIONS: Our findings show the majority of AYA who had care prior to the pandemic continued receiving some element of their multi-disciplinary ED treatment and perceived their care as high quality. None of the markers of care described were statistically associated with increased ED thoughts and behaviors.

The COVID-19 pandemic has had a negative impact on our global community's mental health, in particular those struggling with psychiatric illnesses, such as eating disorders (ED). Stay-at-home orders and social distancing have limited in-person access to ED treatment and as a result, many care providers have transitioned to using videoconferencing platforms. Clinicians who care for patients with EDs worry that these sudden changes in accessing treatment, on top of mental health challenges associated with the pandemic, may contribute to worsening ED symptoms. In this study, we asked adolescent and young adult patients with EDs about their symptoms, access to treatment, changes in care, disruptions in treatment and quality of care since the pandemic started. Our results demonstrate that patients with established care teams have maintained treatment and perceive their care as high quality, though the majority are experiencing worsening ED thoughts and behaviors. Patients who perceive their quality of care as worse than usual might be more likely to have intrusive ED thoughts. Continued access to care could also be protective against increased ED behaviors. Ultimately, our study highlights the need for continued support of patients during this challenging time.