Food habits of children aged 2 to 6 years in a community school during COVID-19 times: descriptive study

Introduction: In times of the COVID-19 pandemic and social distancing it is paramount to pay attention to infancy food habits in order to maintain good health, immunity, and to prevent immediate and future diseases.

A Single-Center Study Surveying Neurology Trainees and Faculty's Perceptions of the Impact of the COVID-19 Pandemic on Residents ' Medical Education

Objective: To assess perceptions of our neurology residents and faculty regarding training experience and medical education during the early COVID-19 pandemic. Background: The Coronavirus Disease 2019 (COVID-19) pandemic has changed healthcare systems. The pandemic presented practical and logistical challenges that disrupted medical education and training. Henry Ford Health System (HFHS) adopted a quick plan in response to the severity of the situation and the number of patients afflicted with COVID-19 that included modifications to training program routine workflow and didactics to comply with social distancing measures and limit the exposure of trainees. Design/Methods: We distributed two online, voluntary and anonymous surveys to trainees and teaching faculty of our neurology department at Henry Ford Hospital. Surveys inquired about trainees' stress, wellbeing, clinical experience, and satisfaction with medical education and available support resources during the first wave of the COVID-19 pandemic in Michigan. Results: 17/31 trainees and 25/42 faculty responded to the surveys. Eight (47%) trainees reported high stress levels. Nine (57%) were redeployed to cover COVID-19 units. Compared to nonredeployed trainees, redeployed residents reported augmented medical knowledge (89% vs 38%, p=0.05). There was no difference in the 2 groups regarding overall satisfaction with residency experience, stress levels, and didactics attendance. Twenty-one (84%) faculty felt that the redeployment interfered with trainees education but was appropriate, while 10 (59%) trainees describe a positive experience overall. Both trainees and faculty believed the pandemic positively impacted trainees experience by increasing maturity level, teamwork, empathy, and medical knowledge, while both agreed that increased stress and anxiety levels were negative outcomes of the pandemic. Twelve (70%) trainees and 13 (52%) faculty were interested in pursuing more virtual didactics in the future. Conclusions: Our findings provide an objective assessment of residents' experience during the COVID-19 pandemic and can guide teaching programs in their medical education response in the face of future global crises.

Extended Thromboprophylaxis in Patients with COVID-19

Introduction Patients hospitalized with COVID-19 have an increased incidence of venous thromboembolism (VTE) and arterial thromboembolism (ATE) events. These thrombotic events increase readmission and mortality rate in COVID-19 survivors who are recently discharged from hospital. To lower the risk of VTE, a short course of post-discharge anticoagulation at either prophylactic or therapeutic dose has been variably prescribed among different facilities to COVID-19 patients. This practice, however, is challenged by less than 3% incidence of VTE in unselected patients. The net clinical benefit of extended thromboprophylaxis beyond hospitalization remains unclear. Methods We conducted a retrospective multicenter observational study of 5613 hospitalized COVID-19 patients. After applying the inclusion and exclusion criteria, 2838 patients were included in statistical analysis. Patients were excluded if they had negative SARS-CoV-2 PCR, remained hospitalized at the time of analysis, or were discharged to hospice service. The first symptomatic ATE and VTE events up to 90 days after patients' discharge from their index admission for COVID-19 were identified using ICD-10 codes, and subsequently validated by chart review. The predictors for post-discharge VTE were identified using multivariate logistic regression. The average protective effect of anticoagulation was assessed using inverse propensity score weighting. Results The mean age (SD) of our cohort was 63.4 (16.7) years old and 47.6% were male. Black, white and other races were 38.9%, 50.7% and 10.3%, respectively. Thirty-six (1.3%) patients developed post-discharge VTE events that require hospital visits (18 deep vein thromboses, 16 pulmonary embolisms and 2 portal vein thromboses). Fifteen (0.5%) patients developed post-discharge ATE events (14 acute coronary syndromes and 1 transient ischemic attack). The incidence of VTE decreased with time (p <.001) with the median event time of 16 days (Figure 1). The incidence of ATE was unchanged with time (p =.369) with the median event time of 37 days (Figure 1). Patients who had a history of VTE (OR=3.24, 95% CI 1.34-7.86), peak D-dimer >3 µg/mL (OR=3.76, 95% CI 1.86-7.57), and predischarge C-reactive protein >10 mg/dL (OR=3.02, 95% CI 1.45-6.29) were at a high risk of developing VTE after hospital discharge (Figure 2). A short course of prophylactic or therapeutic anticoagulation after hospital discharge markedly reduced VTE (OR=0, 95% CI 0-0, p<.001, and OR=0.176, 95% CI 0.04-0.75, p=.02, respectively). Conclusions Although extended thromboprophylaxis in unselected COVID-19 patients is not recommended, post-discharge anticoagulation may be considered in high-risk patients who have a history of VTE, peak D-dimer >3 µg/mL and predischarge C-reactive protein >10 mg/dL if their bleeding risk is low. Our study has provided the first evidence to guide the selection of hospitalized COVID-19 patients who may benefit from post-discharge anticoagulation. [Formula presented] Disclosures: Kaatz: Gilead: Consultancy;Novartis: Consultancy;CSL Behring: Consultancy;Bristol Myer Squibb: Consultancy, Research Funding;Alexion: Consultancy;Pfizer: Consultancy;Janssen: Consultancy, Research Funding;Osmosis Research: Research Funding.

Post hospital discharge thrombosis in patients with COVID-19

Background : Coronavirus disease 2019 (COVID-19) is associated with a high incidence of thrombotic events during hospitalization, however, the need for postdischarge thromboprophylaxis remains unclear. Aims : To quantify the 90-day post hospital discharge rates of venous and arterial thromboembolism in COVID-19. Methods : A retrospective single institution observational study of adult patients hospitalized with COVID-19 confirmed by positive SARS-CoV-2 testing from 3/1/2020 to 8/31/2020. Patients were excluded if they: remained hospitalized at time of analysis, died during hospitalization or were discharged to hospice. For patients with multiple admissions related to COVID-19, the first admission was included. Thromboembolism was identified with ICD-10 codes up to 90 days of discharge: pulmonary embolism (PE: I26), deep vein thrombosis (DVT: I82), portal vein thrombosis (I81), intracranial venous thrombosis (I67),transient ischemia attack (TIA: G45), stroke (I63), acute coronary syndrome (ACS: I20, I21, I22, I24), intracardiac thrombosis (I23, I51.3), and acute limb ischemia (I74). Results : Of 1653 hospitalized patients, 26 (1.6%) developed post discharge venous thrombosis events (12 PE, 13 DVT and 1 portal vein thrombosis). Eleven (0.7%) post discharge arterial thrombosis events were observed(1 TIA and 10 ACS). The risk of VTE decreases with time (Mann-Kendall trend test P -value < 0.001) with median event time 15.5 days (IQR: 6-27). The risk of arterial thrombosis is constant with time (Mann-Kendall trend test P -value = 0.86) with median event time 54 days (IQR: 24-65). Conclusions : The rate thromboembolism is relatively low among COVID-19 patients after they leave the hospital. Results of ongoing randomized trials of the efficacy of post-discharge anticoagulation prophylaxis are eagerly awaited.

Safety of B cell depleting effects of ocrelizumab in patients with multiple sclerosis in clinical practice

Introduction: Ocrelizumab is a humanized monoclonal antibody that targets CD20 expressing cells. It rapidly depletes circulating B-cells that express CD20. However, it has a prolonged peripheral B-cell depleting effect, relatively less well-understood effect on tissue compartment B-cell population, and complex cross-talk with T-cells. Therefore, there is considerable interest in the short and long-term safety of ocrelizumab, mainly regarding severe infections and malignancies. Objective: To investigate the safety of ocrelizumab therapy in relapsing-remitting (RRMS), secondary-progressive (SPMS) and primary progressive multiple sclerosis (PPMS) patients including the incidence of infections and malignancies. Methods: This retrospective study included MS patients receiving ocrelizumab therapy for up to 46 months. Patients' demographic, duration of disease, phenotype, expanded disability status scale(EDSS), course of treatment, number of infusions, infusion site reactions, infection, and laboratory data were recorded. Wilcoxon two-sample tests were used to compare patient with and without infections. Results: Of the 187 patients, 67% were female, 66% were White, 21% were Black, median EDSS was 6 (range 0-8.5), and the mean age was 50.7 years. RRMS(55%) was the most common type of MS with an equal number of both PPMS and SPMS(22%), and the median duration of MS was ten years. Twenty-seven(14%) patients had infusion site reactions primarily mild, with only 2 patients having an anaphylactic reaction. Fifty-two(28%) patients had an infection, the most common being recurrent UTI , 9 with URI, 7 with COVID-19 infection, and 7 with pneumonia, out of which 5 were severe. 6(3%) patients had a cancer diagnosis after the start of treatment. In contrast, 13(7%) had a cancer diagnosis before starting treatment. Infections were associated with older age(p=0.01), higher EDSS at last clinic visit(p=0.046) and more infusions(p=0.031). Conclusion: The rate of infections in clinical settings seems similar to reports from clinical trials, but cancer rates were slightly higher. Advanced age and higher disability status increased the risk of infections.

Patients and providers satisfaction with telemedicine at the beginning of the COVID 19 pandemic-a neurology department experience

Objective: To assess patients' and providers' perspective and experience with rapid implementation of telemedicine in outpatient setting at onset of COVID 19 pandemic. Background: Telemedicine in outpatient setting has been sparsely used in Neurology Department prior to COVID19 pandemic. The COVID-19 pandemic forced an unprecedent reorganization of clinical care delivery worldwide. Understanding the experience and satisfaction with telemedicine is important to finding pathways for improving the health care delivery in ambulatory setting. Design/Methods: Electronic Medical Records from a large southeastern Michigan health system were queried for adult neurology visits between March-May 2020. Surveys containing questions on experience and satisfaction with telemedicine visits were sent to patients and providers. Sociodemographic and reason for visit data were collected from patients and providers. Results: Out of over 3000 televisits, 276 patients responded of which 66% were female, 75% white, 42% had a telephone, 29% a video, 26% had both appointments. Mean age was 60.8. 85% reported a satisfactory experience, receiving expected amount of information (71%). Over 50% felt it was easy to schedule a visit and had less waiting time than clinic visit. 92% reported acceptable video/audio quality during telemedicine visit and 70% preferred combination type of visits in the future, while 8% preferred only televists. Out of 34 neurologist responders, 64% were female, 61% white, 42% had <5 years in practice, 64% did not have previous telemedicine experience. 88% reported at least moderate satisfaction, 61% preferring video and 3% telephone encounters. Providers felt that through telemedicine they satisfied patients' concerns 65%, completed history and counseling satisfactory (80%), but not physical examination (20%). 86% plan on using telemedicine in the future. Conclusions: Patients and providers had satisfactory experience with telemedicine during COVID 19 pandemic, suggesting that telemedicine is feasible for adult neurology care. However, the majority of patients prefer a combination of telemedicine and clinic visit.

Impact of COVID-19 on acute ischemic stroke care at henry ford Hospital's Detroit and West Bloomfield Campuses

Background: Coronavirus 2019 (COVID19) has impacted acute stroke (AS) care with several reports globally showing drops in AS volumes during the pandemic. We studied the impact of COVID19 on AS and transient ischemic attack (TIA) care in a health system serving Southeast Michigan as we rolled out a policy aimed at limiting admissions and transfers. Methods: In this retrospective study conducted at 2 hospitals, we included consecutive patients presenting to the emergency department (ED) for whom a Stroke Alert (SA) was activated during the period 3/20 to 5/20/20 (COVID) and a similar period in 2019 (pre-COVID). We compared demographics, time metrics, and discharge outcomes. Results: 264 patients were seen pre-COVID compared to 121 during COVID (p<0.001). Patients seen during COVID had an equal proportion of males (55% vs 51%, p=0.444), were majority African American (57 vs 58%, p=0.74), but had a higher presenting NIHSS (median: 5 vs 2, p=0.01) and longer times since last-known-well to ED arrival (median: 9.4 vs 4.8 hours, p=0.03) compared to pre-COVID. Fewer patients were transferred from other centers (42 vs 27% p=0.008). SA activation on arrival (median: 9.6 vs 15 min, p=0.004) and imaging initiation from arrival (median: 26.4 vs 34.8 min, p=0.042) were faster as well as a trend toward statistical significance for time to tPA administration (median: 37.8 vs 51 min, p=0.051) compared to pre-COVID. There were higher rates of AS and TIA (69% vs 55%) and lower rates of stroke mimics (17 vs 37%, p<0.001). Patients discharged from the stroke unit had significantly higher discharge NIHSS (median: 3 vs 2, p=0.002) and were more likely to have an unfavorable discharge mRS (3-6) (56 vs 33%, p=0.004). There were no significant differences in medical, social histories, time to first pass for patient undergoing thrombectomy and stroke etiologies between the groups. In 2020, 9 patients (8%) were COVID19 positive, 2 had unfavorable mRS 3-5 while 3 died. Conclusion: There was greater than 50% reduction in stroke admissions during the COVID19 pandemic which is consistent with other reports. Although patients were managed more quickly, they tended to have more severe strokes, fewer stroke mimic diagnoses, and worse outcomes compared to patients treated in the pre-COVID period.

Impact of COVID-19 on thrombolysis and thrombectomy time metrics at henry ford hospital's Detroit and west bloomfield campuses

Background: We propose that social distancing policies during COVID-19 may have negatively impacted the timely administration of intravenous tPA and mechanical thrombectomy (MT) in acute ischemic strokes (AIS). Methods: In this retrospective study conducted at 2 large stroke centers serving Southeast Michigan, we included consecutive patients admitted to our stroke unit from 3/20/20 to 5/20/20 (COVID) and a similar epoch in 2019 (pre-COVID). We compared demographics and time metrics. Results: 247 patients with AIS were included in the tPA analysis, 167 (68%) in 2019 vs 80 (32%) in 2020. Overall mean age was 67.2, 60% male and 49% African Americans (AA). tPA was given in 13/80 in 2019 vs 17/167 patients in 2019 (16% vs 10%, p=0.143). There was no difference in tPA rates between AA and non-AA in 2020. There was a trend toward faster tPA administration in 2020 vs 2019 (median: 37.8 vs 51 min, p=0.051), significant among AA (37.8 vs 58.8 min, p=0.029). Mild/rapidly improving strokes was less frequently a tPA exclusion in 2020 vs 2019 (0% vs 10%). Delayed presentation was significantly less frequent among non-AA in 2020 vs 2019 (54% vs 66%, p=0.045) but there was a trend toward more frequent delayed presentations in AA vs non-AA in 2020 (76 vs 54%, P=0.073). 69 patients were eligible to receive MT, 42 (61%) in 2019 and 27 (39%) in 2020. Mean age was 67.9 and 36% were AA. No differences were detected between 2019 and 2020 in MT rates or time metrics. In 2020, there was a slight trend toward lower MT rates for AA vs non-AA patients (69% vs 30%, p=0.10). Conclusion: During the COVID-19 pandemic in Detroit there was a trend toward faster tPA administration compared to the same period pre-COVID, especially among AA. There was no significant difference in MT rates or time metrics. In our AA-majority city, there was a trend towards more delayed presentations and lower MT rates among AA during COVID. The reasons for these differences are yet to be determined and warrant further research.