Fresh Versus Cryopreserved Allograft Outcomes in Peripheral Blood Stem Cell Transplantations

Background: The emergence of the COVID-19 pandemic saw an increased use of cryopreserved (cryo) peripheral blood (PB) grafts for allogeneic hematopoietic stem cell transplantation (HSCT). Outcomes of patients receiving either fresh or cryo grafts have yielded heterogeneous results. Herein, we retrospectively compared the outcomes of patients receiving fresh and cryo grafts at a single center.(Table Presented)Methods: Between 2019 and 2021, we reviewed data from 380 patients;167 (44%) received a fresh, and 213 (56%) received a cryo graft. Patients underwent myeloablative or nonmyeloablative HSCT from either matched or mismatched, related or unrelated donors. Cell doses were determined by number of donor cells collected and recipient weight at infusion. Engraftment, disease risk (DR) and acute GVHD were classified based on established criteria. Donor chimerism was collected at approximately day 28 and day 80 after HSCT. Unadjusted and adjusted estimates of overall survival (OS), relapse, and non-relapse mortality (NRM) as a function of time were obtained. The adjusted odds (grades III-IV acute GVHD) and the adjusted cause-specific hazard of failure (all other outcomes) were compared between the 2 groups. with the use of logistic (Figure Presented) or Cox regression, respectively. These models were adjusted for various factors known to be associated with each outcome. Result(s): The characteristics of patients between the 2 groups are shown in Table 1. There was a higher proportion of patients with high/very high DR in the fresh graft group (Table 1). Median time to neutrophil engraftment was 17 and 18 days in fresh vs. cryo, respectively. The adjusted hazard ratio (HR) of neutrophil engraftment (fresh vs. cryo) was 1.07 (95% CI, 0.86-1.34, p=0.54). Median time to platelet engraftment was 13 and 15 days, respectively, and the adjusted HR of platelet engraftment was 1.32 (1.06-1.65, p=0.01). Day 28 chimerism data were available for 272 patients (113 fresh and 159 cryo). At day 28, donor CD3 chimerism was below 50% in 5 out of 113 (4.4%) and 17 out of 159 (10.7%) patients receiving fresh and cryo grafts, respectively (p= 0.06). At day 80, 3 out of 121 (2.5%) patients in the fresh group and 4 out of 165 (2.4%) in the cryo group had CD3 chimerism below 50%. The adjusted HRs (fresh vs. cryo) for death and NRM were 0.83 (0.54-1.28, p=0.40) and 0.71 (0.38-1.33, p=0.29), respectively (Figures 1 and 2). The adjusted HR for relapse was 0.65 (0.42-0.99, p=0.05) (Figure 3). The adjusted odds ratio (fresh vs. cryo) for grades III-IV GVHD was 1.65 (0.94-2.9, p=0.07). Conclusion(s): In this single-center retrospective study we observed numerically better outcomes with fresh grafts relative to cryo grafts for all examined endpoints with the exception of grades III-IV aGVHD, although none of the differences were definitive with the possible exception of relapse and platelet engraftment. Further studies are needed to confirm our observations.Copyright © 2023 American Society for Transplantation and Cellular Therapy

Progression of Overactive Bladder Symptoms in Patients with Prior Sars-Cov-2 Infection

INTRODUCTION AND OBJECTIVE: Infection with SARS-CoV- 2 can result in de novo or worsening genitourinary (GU) symptoms, such as frequency, urgency, nocturia, and pain/pressure, also referred to as COVID-19 associated cystitis (CAC). The aim of this study was to follow progression of OAB symptoms in patients that previously reported new or worsening OAB symptoms after COVID-19 diagnosis. METHOD(S): 19,128 individuals from a Beaumont COVID-19 serology study, were invited to participate in a follow-up study, with 2,137 subsequent respondents. Participants were divided into a COVID-, Ser+ (positive serology test only) or PCR+ (positive PCR test) groups. Initially, patients were asked to score their OAB symptoms retrospectively prior to the pandemic (baseline) and at present time (day 0). Participants were subsequently asked to score their symptoms at 2-, 4-, 8- and 12-months follow-up. Participants that obtained COVID-19 diagnosis during follow-up phase were excluded from the study. GU symptoms were assessed using the ICIQ-OAB. The minimal important difference (MID) of ICIQ-OAB of 1 is considered a significant change. Data was collected between May 2021 and July 2022. RESULT(S): Of 2,137 participants, 564 (26.4%) previously tested positive for COVID, and 1,573 (73.6%) were COVID naive (COVID-). Of these, 592 participants reported a >=1 unit increase in OAB score at study onset (Day 0) compared to pre-pandemic;243 (41%) were COVID-, 129 (21.8%) had positive serology test (Ser+), and 220 (37.2%) were COVID+ based on PCR test (PCR+). OAB score of these three cohorts were similar at pre-pandemic (2.71 vs 2.97 vs 2.53;p=0.193) but significantly higher at start of study (day 0) in PCR+ versus COVID- or Ser+ groups (5.83 vs 5.12 vs 5.33;p=0.019). In prospective follow-up, change in ICIQ-OAB scores from baseline were recorded at 2, 4, 8 and 12 months. At day 0, both Ser+ and PCR+ cohorts had significantly higher change in OAB score than COVID- group (2.8 and 3.11 vs 2.16;p=0.001). However, after 12 months follow-up, change in OAB score was similar between COVID- (1.86), Ser+ (2.15) and PCR+ (2.09). By 12 months, 74% of COVID-, 80.5% of Ser+ and 72.4% of PCR+ participants still reported significant increase in ICIQ-OAB scores from pre-pandemic levels. CONCLUSION(S): We previously demonstrated that COVID-19 infections increases the risk for developing CAC. COVID infected individuals with CAC take up to 12 months to reach levels of COVIDpatients with baseline elevated OAB Symptoms. Elevated ICIQ-OAB scores in COVID- participants may be contributed to other consequences of the pandemic such as elevated stress and depression.

Echocardiographic assessment of left ventricular structure and function in hypertensive disorders of pregnancy at six months and two years postpartum

Purpose: Hypertensive disorders of pregnancy (HDP) are associated with longer term postpartum cardiovascular sequelae, including double the risk of ischaemic heart disease and cardiovascular mortality (1). Transthoracic echocardiograms (TTE) were performed in women with pregnancies complicated by gestational hypertension and pre-eclampsia, or uncomplicated pregnancy, at six months and two years postpartum. The aim was to longitudinally assess cardiac structure and function in women with HDP and compare this to women who had a normotensive pregnancy. The six-month results have been previously reported, we now present the two-year data. Method(s): A prospective cohort study was conducted in a pre-specified subgroup of 126 patients within a single, tertiary referral centre as part of the P4 (Post Partum, Physiology, Psychology, and Paediatric Follow Up) study (2). 74 (59%) women had a normotensive pregnancy, and 52 (41%) had a pregnancy complicated by HDP. Women with pre-existing hypertension were excluded from the study. The mean patient age at time of six-month postpartum TTE was 32 years (range 22-47 years). TTEs were performed by blinded experienced sonographers and reported by a single blinded imaging cardiologist. Result(s): Six months postpartum. 126 women underwent TTE at six months postpartum. Although all results fell within normal ranges, compared to women with a normotensive pregnancy, those with HDP had increased left ventricle (LV) wall thickness, higher relative wall thickness, and increased LV mass. E/A ratio was lower, and E/E' ratios higher in the group with pregnancy complicated by HDP, indicating a trend towards poorer diastolic function (2,3). Two years postpartum. 35 women completed a two year postpartum TTE (18 normotensive, 17 HDP). Measurements fell within normal ranges in both groups of women. At two years postpartum, women with HDP had larger BSA (1.9 vs 1.71 2 p=0.003), larger LV internal diastolic diameter (48.4 vs 45.5mm p=0.017) and increased inter-ventricular septum thickness (8.5 vs 7.7mm p=0.007) compared to those with normotensive pregnancy. LV mass was greater in women with HDP (98.1 vs 81.5g), as was LA volume indexed (25.4 vs 23.4 cm3/m3), however these differences did not reach significance (p=0.053 and 0.196 respectively). Compared to normotensive women, those with HDP had higher septal (8.7 vs 7.3 p=0.014) and lateral (6.6 vs 5.4 p=0.017) E/E' ratios, indicating a trend towards diastolic dysfunction. Conclusion(s): Despite measurements falling within normal ranges, our results indicate that women with HDP have changes in cardiac structure and function that persist out to two years postpartum. Limitations exist due to incomplete follow up, leading to small sample size;this was partially due to restrictions on service provision in the context of the COVID-19 pandemic. (Table Presented).

SUPPORTING DEMENTIA CAREGIVERS DURING COVID-19 WITH CAREHEROES IT: USAGE PATTERNS AND OUTCOMES

Caregivers of people with dementia often experience negative physical and mental health outcomes due to the complex challenges posed by dementia symptoms and navigating care systems. The COVID-19 pandemic posed even greater hurdles for caregivers as many health care and support services transferred to virtual formats and required increased use of information technologies (IT). This research examined usage data and psychosocial outcomes of dementia caregivers who used a new mobile-enabled web-based app that was offered as an adjunct to clinical care at two memory clinics (Birmingham, AL;Miami, FL) during the pandemic. This app, called CareHeroes: (1) allows caregivers to self-assess their emotional and mental health;(2) offers a secure platform for tracking and communicating patient-related information among caregivers and providers;and (3) offers caregiver education. CareHeroes is also available in Spanish. Effort was made to recruit digitally underserved populations of caregivers (e.g., rural dwelling, underserved racial/ethnic groups). This presentation will review caregiver outcomes (e.g., burden, depression, user data) at baseline and 3-month follow-up. Among the 22 caregivers who enrolled in the study, 17 completed baseline and 3-month follow-up interviews. Over a 14-month period, participants logged onto CareHeroes 131 times, which varied by month. Caregivers most often used CareHeroes to complete assessment tools. Findings indicate that depression and burden were lower at 3-month follow-up compared to baseline, though this reduction was not statistically significant. The presentation will also review challenges of integrating a new technology intervention designed to promote telehealth during the COVID-19 pandemic.

Patients Who Choose in Person Vs Telehealth First Visit Appointments: Differences in Baseline Characteristics and Engagement in Care

Objective: To evaluate if there are differences in baseline characteristics or engagement patterns of patients who choose telehealth (audio and video) first visit compared to those who are seen in person. Material(s) and Method(s): A retrospective cohort study of all new patient visits between April of 2020 and March of 2021 at a university-affiliated fertility center was performed. Patients who engaged in a telehealth new patient visit were compared to those with an in-person new patient visit. Outcomes were divided into those who presented pregnant (Group A), did not complete diagnostics (Group B), completed diagnostics and did not pursue treatment (Group C), proceeded with diagnostics and treatment but did not proceed to IVF (Group D), underwent oocyte retrieval without success (Group E), and with successful discharge to obstetrical care (Group F). Statistical analyses were performed using SPSS. Result(s): A total of 5678 patients were included in the analyses. Of those, 4291 had an in person first visit and 1387 had a telehealth visit. Patients who had a telehealth first visit were older (35.4 vs 35.1;p=0.018), had a lower BMI (26.9 vs 27.6;p=0.001), and lower AMH (3.4 vs 4.0;p<0.001), when compared to those who had an in-person first visit. There was no difference between the groups in having a partner, having a same sex partner, or baseline serum FSH. Patients who had an initial telehealth visit were slightly less likely to complete diagnostics, move on to treatment, or proceed to IVF, however were slightly more likely statistically to have a successful discharge to obstetrical care after frozen embryo transfer (see Table). [Formula presented] Conclusion(s): Although we identified statistically significant differences between patients choosing telehealth first visits compared to those choosing in person first visit, these are unlikely to be clinically significant. No specific factors were noted that should make the practitioner more wary of offering telehealth visits. Impact Statement: Telehealth became increasingly utilized and accepted during the Covid-19 pandemic, and should be continued to be offered to our patients, as there is little difference in how patients engaged in care compared to those who underwent an in person new patient visit. Support: None REFERENCES: None Copyright © 2022

Territory Glimpsed Through Lache Eyes: A Tale of Non-Euclidean and Symbolically Authentic Excursions in Liminal Space

The title of this chapter has been adapted from René Daumal’s unfinished pataphysical novel, published posthumously in 1952, Mount Analogue: A Tale of Non-Euclidean and Symbolically Authentic Mountaineering Adventures. Conceived in and reflecting on the period of lockdown imposed by the UK Government from March 2020 in response to the COVID-19 global pandemic, the chapter is an attempt to both delineate and dissolve the parameters of a hyper-localised and, ultimately, existential space of territory conditioned by the experience of lockdown. Geographically and poetically, attention is focused on a small patch of reclaimed marshland – ‘Lache Eyes’ – that is located on the England–Wales border near the town of Saltney in North Wales. Restricted to taking outdoor exercise within the immediate environs of the author’s home, during lockdown this liminal territory became an immersive space into which a meshwork of historical, familial, psychogeographical and critical-creative entanglements have inchoately fed. Drawing inspiration from Daumal’s pataphysics and J. G. Ballard’s explorations of ‘inner space’ (as set out in his short story ‘The Enormous Space’, adapted for television by the BBC in 2003 and renamed Home), the chapter follows a poetic-inductive method that serves as a catalyst for the re-imagining of the science of territory as the territoriological science of imaginary solutions. © 2022 selection and editorial matter, Andrea Mubi Brighenti and Mattias Kärrholm;individual chapters, the contributors.

MATERNITY STAFF PERCEPTIONS OF EFFECTS ON ANTENATAL SCREENING AND SERVICES FOR MENTAL HEALTH AND DOMESTIC VIOLENCE DURING THE COVID-19 PANDEMIC: A SURVEY STUDY

Background: Domestic and family violence (DFV) and mental health screening are core components of antenatal care. However, the COVID-19 pandemic both increased the prevalence of DFV and mental health issues and resulted in many antenatal visits becoming telehealth. DFV and mental health screening were consequently often delayed, potentially resulting in insufficient time to establish support systems before birth. This study assessed pandemic effects on DFV and mental health screening from the perspective of local maternity service providers. Methods: Maternity staff (midwives, doctors, allied health) at three Sydney metropolitan hospitals were surveyed regarding perceived impact of COVID-19 on the delivery, timeliness, and quality of overall pregnancy care, DFV and mental health screening and care, and their telehealth perceptions. Responses by hospital and maternity care provider subtype were compared. Results: Of 109 respondents, most felt the pandemic negatively impacted overall pregnancy care (60%), DFV screening/care (57%), and mental health screening/care (57%), significantly more believing COVID-19 'extremely' negatively impacted DFV screening (p = 0.02). Staff at the hospital with highest sociodemographic diversity were significantly more concerned about DFV screening/ care. Nominated telehealth advantages e.g. reduced travel (69%) and clinic overcrowding (62%) were fewer than disadvantages including no physical examinations (90%), difficulties picking up non-verbal cues (84%), and certain questions unsafe (62%). Fiftysix percent believed telehealth should be used for some antenatal care for select women (low-risk, multiparous). Conclusions: Telehealth may have an ongoing limited role in maternity care in Australia for low-risk women. Staff considered those high-risk for physical and/or psychosocial reasons unsuited to telehealth care.

THE INCIDENCE OF NEW OR WORSENING OAB SYMPTOMS IN PATIENTS WITH PRIOR SARS COV-2 INFECTION

INTRODUCTION AND OBJECTIVE: Investigators from our institution were the first US group to identify de novo genitourinary symptoms, such as frequency, urgency, nocturia, and pain/pressure, in individuals with prior COVID-19 infection. They termed this condition COVID-19 associated cystitis (CAC). Our study aims to establish the incidence of worsening or de-novo CAC, and to determine the correlation of CAC with serology status and antibody levels. METHODS: After IRB approval, 19,128 individuals from the largest COVID-19 serology study (BLAST COVID Study Group) were invited to participate in a follow-up study, with 1,895 subsequent respondents. Participants were retrospectively asked to score their OAB symptoms at three different time points: prior to the pandemic, 2 months after COVID-19 infection (if applicable), and at the present time. Genitourinary symptoms were assessed using the ICIQ-OAB. RESULTS: Of the 1,895 participants, 81.7% (n=1,548) were female, 16.5% male (n=312), 1.9% other/unknown (n=35). Most were Caucasian (85.8%), followed by African American (4.1%), Asian (3.8%), and Hispanic (1.4%). A third of participants (n=605) were COVID-19 positive as defined by positive serology or PCR test. Of these, 492 had 2 months post infection data with 36.4% (n=179/492) reporting an increase of ≥1 unit on the ICIQ-OAB compared to pre-pandemic. Out of these, 22% (n=40/179) were de novo. Comparing prepandemic to present symptoms, 35.7% (n=219) of participants with prior COVID-19 infection had an increase of ≥1 unit on the ICIQOAB, compared to 15.7% (n=202) of uninfected patients (OR: 2.99, 99.6Cl, 2.21, 4.05, p <0.001). The minimal important difference (MID) of ICIQ-OAB of 1 is considered a significant change. Antibody levels were not correlated with OAB symptoms in those with a positive PCR (ρ==-0.10) and were weakly correlated in those with a positive serology test (ρ= 0.14). CONCLUSIONS: In this study, we demonstrate that patients infected with COVID-19 are at increased risk for developing new or worsening OAB symptoms. No correlation was found between antibody levels and OAB symptoms in patients with prior COVID-19 infection. Participants are being followed prospectively to assess the progression of OAB symptoms in patients with CAC.

RATES OF COVID-19 INFECTION IN A FERTILITY TREATMENT POPULATION

OBJECTIVE: To assess rates of COVID-19 positivity in a fertility treatment population who continued to seek care throughout the pandemic. MATERIALS AND METHODS: A retrospective chart review of all patients actively pursuing fertility treatment and had a positive COVID-19 test between March 2020 and February 2021 at a University-affiliated IVF center was performed. Testing was performed on medication start date, and regularly throughout the treatment cycles, approximately once a week. Social distancing, mask use, and temperature and symptomatic screening was implemented early in the process. Rates of infection were calculated by dividing COVID-19 positive patients (whether symptomatic or asymptomatic) by total number of patients in care. This was then multiplied by 100,000, in order to compare our rates to the rate of cases in the state. Information on the general population's COVID-19 positivity rate was obtained from the State Department of Health. RESULTS: Rates of infection in our treatment population varied from 55 in August of 2020 to a high of 2333 per 100,000 in April of 2020. Rates of infection in the general population ranged from 167 per 100,000 to a high of 1367 in Nov of 2020. Our rates of infection did see a trend that was consistent with the curve of infections seen in the general population in the state (Table 1). CONCLUSIONS: Rates of infection were consistently at or below the state's rate per month for much of the 12-month period of study. The exceptions to this included April 2020, where we suspect that patients undergoing treatment were more likely than the general population to receive testing due to the center's testing policies compared to the lack of tests for the general population. Indeed, throughout the studied period, the patients receiving fertility treatment were much more likely than the general population to receive a test, as they were undergoing testing while asymptomatic. Additionally, the rate in February of 2021 was higher than that of the general population. IMPACT STATEMENT: The Covid-19 pandemic was unprecedented in the history of gynecologic endocrinology and infertility, and impacted the ability of patients to access fertility care worldwide. Our findings reveal that with proper mitigation techniques, infertility treatment can be safely delivered even in the face of a pandemic without radically increasing the risk of infection. (Table Presented).

FIRST TRIMESTER OUTCOMES OF PATIENTS SEEKING INFERTILITY CARE AFTER COVID-19 INFECTION

OBJECTIVE: To assess if COVID-19 infection differentially impacts first trimester outcomes in patients seeking infertility care at one large fertility practice. MATERIALS AND METHODS: A retrospective chart review of all female patients actively pursuing fertility care in a single fertility center with positive COVID-19 test results from March 2020 to February of 2021 was performed. Positive COVID-19 test results included PCR tests performed in our clinic and symptomatic patients who informed us of their outside positive test results by phone during their treatment with our clinic. This was compared to a control group of all comers in our clinic in 2020. Information was gathered on infertility treatment type, and pregnancy outcomes. Chemical pregnancy rate (CPR) is documented as a positive pregnancy test and ongoing pregnancy was documented as a positive fetal heart beat between 7-8 weeks of gestation and discharge to routine OBGYN care. Fishers exact test was used to calculate p value, statistically significant associations were considered to exist when the p value ≤0.05. RESULTS: A total of 178 cases of COVID-19 were documented in patients between April 2020 and February 2021. After COVID-19 infection (Covid+) sixty-two pregnancies were documented, with sustained implantation in fifty-three (85%) patients. In the subgroup of Covid+ patients that underwent subsequent fertility treatment the CPR was 30.1% with IUI, and 70.1% with IVF and single frozen embryo transfer. This is in comparison to our control population CPR of 14.1 % with IUI (p=0.002) and 68% (p=0.78) with IVF with single embryo transfer (Table 1). Clinical pregnancy loss rate was recorded and shown in Table 1. CONCLUSIONS: In an infertile population, a recent history of COVID-19 diagnosis did not negatively impact pregnancy outcome as measured against a control population. One of the limitations of this study was the relatively small sample size, which may have conflated our data on COVID-19 patients who underwent IUI, whose higher rate of pregnancy is unlikely to be clinically significant. IMPACT STATEMENT: Patients who have had COVID-19 and then proceeded with infertility treatment were no more likely than our control population to have first trimester complications in one fertility clinic. The findings from this study should provide reassurance that attempts at pregnancy do not need to be delayed after recovery from a COVID-19 diagnosis.

As practice evolves, are consultants and advanced practitioners considered clinical academics?

Keywords: Clinical academic;Consultant;Advanced practice Purpose: With the development of consultant and advanced clinical practice frameworks, there is an urgent need for these highly-skilled practitioners to engage in research to develop the evidence base of the profession. Since there is no universal definition of the term ‘clinical academic’, and clinical academic roles are estimated to make up less than 0.1% of the workforce, the aim of this study was to determine whether consultants, advanced practitioners and their managers consider these to be clinical academic roles. If so, this could potentially increase the critical mass of this important cadre of the workforce, raise the profile of advanced and expert practice, and help legitimise the scholarly component of the role. Methods: The study design was a national survey of consultants, advanced practitioners and managers of these roles, at band 7 or above and practising in the UK. This convenience sample was recruited via social media (Twitter) in March–April 2021 (during the COVID pandemic), with a link to the survey (in Google Forms), and weekly reminders. To ensure face and content validity, the survey content was derived from an earlier post by the senior author seeking definitions of the term ‘clinical academic’ (that generated 25 replies, 61 retweets and 112 ‘likes’) and was piloted with 3 clinical academic consultants and advanced practitioners prior to data collection. Data were analysed using descriptive statistics and content analysis of the open questions. Results: Of the 56 responses, 28.6% (n = 16) were from consultants;58.9% (n = 33) advanced practitioners;10.7% (n = 6) combined manager and consultant/advanced practitioner;and 1.8% (n = 1) manager. The majority of respondents (78.6%, n = 44) were allied health professionals, including 50% (n = 28) physiotherapists, and 80.4% (n = 45) of participants identified as female and 85.7% (n = 48) as white. Forty-nine respondents (87.5%) reported direct patient contact, with their own clinical caseload, and the most prevalent clinical settings were: secondary care (60.7%);tertiary care (23.2%);higher education (17.9%);primary care (12.5%) and community (10.7%). When considering whether consultants should be considered clinical academics, 35.7% (n = 20) answered ‘yes’;46.4% (n = 26) ‘possibly’;and 16.1% (n = 9) ‘no’. Meanwhile the responses considering whether advanced practitioners should be clinical academics were: 17.9% (n = 10) ‘yes’;62.5% (n = 35) ‘possibly’;and 16.1% (n = 9) ‘no’. A plethora of open comments justified these responses. Conclusion(s): Whilst twice as many respondents considered consultants to be clinical academics compared with advanced practitioners, participants most-commonly favoured the option of ‘possibly’, with a minority rejecting this notion. As practice evolves, consultants and advanced practitioners must contribute to developing the evidence-base for the profession, and are ideally placed to identify clinically-important research questions. Further work needs to be done to support clinicians to prioritise and deliver the research pillar in their roles. Impact: The shortage of clinical academic healthcare staff will inevitably limit the development of the evidence needed to improve patients’ outcomes and service delivery. As practice evolves, it is vital to understand the term ‘clinical academic’ and determine whether consultants and advanced practitioners are included in this group, to promote and legitimise the research component of these roles. Funding acknowledgements: This project was unfunded, as it was undertaken in partial fulfilment of pre-registration MSc Physiotherapy degree at the University of Southampton.

The difficult asthma multi-disciplinary clinic: Silver linings of the COVID cloud

Background An estimated 5-10% of children with asthma have problematic severe asthma, defined as asthma which is poorly controlled (chronic symptoms, episodic exacerbations, continued requirement for short-acting b agonists) despite a daily dose of at least 800 mg budesonide or equivalent for 6 months or longer. Such patients should be referred to a specialist difficult asthma team in a tertiary care, in order to facilitate systematic specialist assessment and a multi-disciplinary approach to management. Objectives As with most outpatient services, the delivery of paediatric difficult asthma (DA) clinics was disrupted by the COVID-19 pandemic. Teams were required to restructure clinics and operating procedures, in order to optimise patient care despite the restrictions on face-to-face appointments. This study aimed to assess the impact that the COVID-19 pandemic had on the initial assessment of patients referred to the paediatric DA clinic at a tertiary care, specifically in relation to being seen by the appropriate multi-disciplinary team (MDT) members and having relevant investigations completed. Methods The electronic notes database was interrogated to provide a list of children and young people with asthma referred to the paediatric DA clinic between 1/9/2016 and 31/ 12/2020. In total 144 patients were identified, and their electronic medical records were retrospectively reviewed. Patients were considered to have been seen 'pre-COVID' if their initial appointment in the paediatric DA clinic occurred prior to 23/ 03/2020, and considered to have been seen 'post-COVID' if their initial appointment was on or after 23/03/2020. Results Of the total 144 patients, 130 were initially seen in the paediatric DA clinic pre-COVID and 14 were initially seen post-COVID. In the post-COVID group, fewer patients had fractional exhaled nitric oxide (FeNO) (71%) and spirometry (57%) as part of their initial work-up. In the pre-COVID group, 85% had FeNO measured and 96% had spirometry. This was in contrast to the proportion of patients having a physiotherapy and psychology assessment;in the post-COVID group, 64% had physiotherapy review and 50% had psychology review following their difficult asthma referral, compared to 52% and 26%, respectively, in the pre-COVID group. The wait for initial specialist assessment after being seen in the DA clinic for the first time was also reduced in the post-COVID cohort. The median wait for physiotherapy and psychology assessment decreased from 91 and 180 days in the pre- COVID group to 70 and 35 days, respectively, in the post- COVID group. Conclusions Unsurprisingly given strict restrictions on in-person appointments and aerosol generating procedures, assessment of FeNO and spirometry was lower in patients first seen in the DA clinic post-COVID. However, improvements were seen in relation to physiotherapy and psychology assessment in the post-COVID group, as the physiotherapist and psychologist were able to attend more DA clinics to see new patients at their first appointment. This highlights that changes to working in response to the COVID-19 pandemic can actually help to streamline services and promote early input from the wider MDT when managing patients with problematic severe asthma.

Iga nephropathy after receiving the pfizer COVID-19 vaccine: A case report

Introduction: Here, we present a case of IgA nephropathy in a 22-year-old Caucasian woman with no comorbidities and prior COVID positive infection, after receiving the Pfizer vaccine for COVID-19. She initially presented to her primary care physician for an episode of gross hematuria two days after receiving the first Pfizer COVID -19 vaccine. Case Description: She was asymptomatic for urinary tract infection, neither was she menstruating. Her renal functions were normal with a creatinine of 0.93 mg/dL. Urinalysis showed hematuria with > 50 red blood cells (RBC) per high-power field (HPF) and 2+ protein on the dipstick. She again experienced gross hematuria with > 50 RBC/ HPF on urinalysis and proteinuria of 2.23g after receiving the 2nd Pfizer vaccine, at which time she was referred to the Nephrology department for further evaluation. We examined urine sediment which was significant for dysmorphic RBCs and rare granular casts. A renal biopsy showed that the majority of 14 glomeruli had global sclerosis on light microscopy, a diffuse increase of mesangium, and interstitial fibrosis with tubular atrophy. Immunofluorescence microscopy was positive for Immunoglobulin A (IgA), Lambda light chains, and anti-complement C3 antibodies. Electron microscopy revealed mesangial expansion and cellularity and peri-mesangial electron-dense deposits. These and other findings fit with the Oxford Classification of M1, S1, E0, T0, C0. Following the biopsy, we prescribed Lisinopril 5 mg daily for control of proteinuria. We did not prescribe glucocorticoids due to the mild nature of the disease and lack of underlying inflammation. The patient continues to do well without symptoms. Her most recent labs show preserved renal function and spot proteinuria reduced to 1.3 g. Discussion: The current case raises questions about the potential association of IgA Nephropathy with the COVID vaccine. One of several possible mechanisms includes an aberrant mucosal immune response to the initial SARS-COV-2 infection that she contracted in December 2020. This could have then predisposed her to IgA nephropathy after the administration of the vaccine. The virus' spike protein or other factors may trigger an aberrant mucosal immune IgA response which can then lead to the onset and progression of IgA nephropathy. Further case series are needed to establish a more definitive association of the COVID-19 vaccine with IgA nephropathy.