PREPARE-IBD: Physician responses to disease flares and patient adaptation in relation to events in inflammatory bowel disease during the COVID-19 pandemic: A multicentre cohort analysis

Background: The COVID-19 pandemic continues to pose complex problems across Europe and the world, with rising numbers of infections and the ongoing need for drastic public health interventions. This is difficult for patients with immune-mediated disorders like Inflammatory Bowel Disease (IBD), where immunosuppressive medications may affect susceptibility to serious infection. It was particularly challenging for physicians and patients during the first wave of the pandemic, when it was unclear whether anti-inflammatory flare treatment should be adapted to reduce infection risk, whilst trying to ensure symptomatic control and avoid admission to overwhelmed hospitals. Despite the development of various IBD / COVID-19 databases, the treatment adaptations and outcomes of patients experiencing IBD flares during the COVID-19 pandemic remain undefined. We aimed to compare IBD management and outcomes between pandemic and prepandemic cohorts. Methods: An observational cohort study was performed, comprising patients who contacted IBD teams for a symptom flare between March - June, 2020 in, 60 National Health Service trusts in the United Kingdom. Data were compared to a pre-pandemic cohort after propensity- matching for age and disease severity. Statistical analyses were performed using R (version, 4.1.0, Vienna, Austria). Results: In total, 3728 patients in the pandemic (n=1864) and pre-pandemic (n=1864) cohorts were included. The principal findings were reduced systemic corticosteroid prescription during the pandemic in both Crohn's disease (prednisolone: pandemic, 199/752, 26.5% vs, 263/708, 37.1%;p<0.001) and ulcerative colitis (UC) (prednisolone: pandemic, 372/1112, 33.5% vs, 470/1156, 40.7%, p<0.001), with increases in poorly bioavailable oral corticosteroids in Crohn's (pandemic, 117/752, 15.6% vs, 48/708, 6.8%;p<0.001) and UC (pandemic, 131/1112, 11.8% vs, 60/1156, 5.2%;p<0.001). Ustekinumab (Crohn's and UC) and vedolizumab (UC) treatment also significantly increased during the pandemic. Three-month steroid-free remission was similar in both Crohn's (pandemic, 175/616, 28.4% vs, 195/608, 32.1%;p=0.17) and UC (pandemic, 312/858, 36.4% vs, 404/1006, 40.2%;p=0.095). The, 65 patients experiencing a flare and COVID-19 were more likely to have moderate-to-severely active disease at three months compared to those with a flare alone. Conclusion: Despite several treatment adaptations during the pandemic, steroid-free outcomes were comparable to pre-pandemic levels, though patients with a flare and COVID-19 experienced worse outcomes. These findings have implications for IBD management during future waves or pandemics.

Large differences in IBD care and education across Europe, first results of the pan-european viper survey

Introduction: More than 2.5 million people in Europe are diagnosed with inflammatory bowel diseases (IBD). IBD affects the quality of life, but also has important consequences for health systems. It remains unknown if variations in IBD care and education differs across Europe and to help address this question, we conducted this European Variation In IBD PracticE suRvey (VIPER) to study potential differences. Aims & Methods: This trainee-initiated survey, run through SurveyMonkey ®, consisted of 47 questions inquiring basic demographics, IBD training and clinical care. The survey was distributed through social media and national GI societies from December 2020 - January 2021. Results were compared according to GDP per capita, for which countries were divided into 2 groups (low/high income, according to the World Bank). Differences between groups were calculated using the chi2 statistic. Results: The online survey was completed by 1268 participants from 39 European countries. Most of the participants are specialists (65.3 %), followed by fellows in training (>/< 3 years, 19.1%, 15.6 %). Majority of the responders are working in academic institutions (50.4 %), others in public/ district hospitals (33.3 %) or private practices (16.3 %). Despite significant differences in access to IBD-specific training between high (56.4%) and low (38.5%) GDP countries (p<0.001), majority of clinicians feels comfortable in treating IBD (77.2% vs 72.0%, p=0.04). GDP was not a factor that dictated confidence in treating patients. IBD patients seen per week, IBD boards and especially IBD specific training were factors increasing confidence in managing IBD patients. Interestingly, a difference in availability of dedicated IBD units could be observed (58.5% vs 39.7%, p<0.001), as well as an inequality in multidisciplinary meetings (72.6% vs 40.2%, p<0.001), which often take place on a weekly basis (53.0%). In high GDP countries, IBD nurses are more common (86.2%) than in low GDP countries (36.0%, p<0.001), which is mirrored by differences in nurse-led IBD clinics (40.6% vs 13.8%, p<0.001). IBD dieticians (32.4% vs 16.6%) and psychologists (16.7% vs 7.5%) are mainly present in high GDP countries (p<0.001). In the current COVID era, telemedicine is available in 58.4% vs 21.4% of the high/low GDP countries respectively (p<0.001), as well as urgent flare clinics (58.6% vs 38.7%, p<0.001) and endoscopy within 24 hours if needed (83.0% vs 86.7% p=0.1). Treat-to-target approaches are implemented everywhere (85.0%), though access to biologicals and small molecules differs significantly. Almost all (94.7%) use faecal calprotectin for routine monitoring, whereas half also use intestinal ultrasound (47.9%). Conclusion: A lot of variability in IBD practice exists across Europe, with marked differences between high vs low GDP countries. Further work is required to help address some of these inequalities, aiming to improve and standardise IBD care across Europe.

Performance of Elixhauser and Charlson Comorbidity Indices to predict mortality among adults hospitalized with COVID-19 in the United States

Background: It is not clear how to best control for comorbidities when examining short-term mortality among individuals with COVID-19. The Charlson and Elixhauser Comorbidity Index were developed to predict 1-year and in-hospital mortality, respectively, and both indices can be operationalized using individual comorbidities or a weighted summary score. We compared the predictive accuracy for these comorbidity scores in predicting in-hospital death among adults hospitalized with COVID-19 from 5 hospitals comprising a health care system in the Mid-Atlantic United States. Methods: We used electronic health record data from adults hospitalized for COVID-19 from March 4-November 6, 2020. We ascertained comorbidities using all available lookback data from January 1, 2018 through COVID-19 hospital admission.We operationalized both comorbidity scores using individual comorbidities - 17 for Charlson and 29 for Elixhauser. We calculated weighted Charlson scores four ways, separately, using weights proposed by Deyo (1992), Schneeweiss (2003), Quan (2011) and Mehta (2016).We calculated the Elixhauser comorbidity score using weights proposed by van Walraven (2009) and Thompson (2015). We used logistic regression to compare the performance of different comorbidity scores in predicting in-hospital death. Nine models were constructed (1 baseline model that included age and sex, 1 for Charlson individual comorbidities, 4 for weighted Charlson scores, 1 for Elixhauser individual comorbidities and 2 for weighted Elixhauser scores). All models included age and sex as covariates.We evaluated the performance of each model using the c-statistic, and compared cstatistics using chi-square statistics, with a p-value < 0.05 considered significant model fit improvement. Secondarily, we compared model fit using Akaike Information Criteria (AIC), where lower values indicate better model fit.We used PROC LOGISTIC in SAS version 9.4. Results: Of 2,815 COVID-19 hospitalized patients, 12% (n=349) died in the hospital. Each comorbidity score performed significantly better (p < 0.001) than age and sex alone (c-statistic 0.775) at predicting COVID-19 related death. Overall, the ranking of the top 4 comorbidity scores were as follows: individual Elixhauser comorbidities (c-statistic 0.822) > Elixhauser-Thompson (c-statistic 0.803) > Elixhauser-van Walraven (c-statistic 0.796) = individual Charlson comorbidities (c-statistic 0.796).Weighted Elixhauser comorbidity scores (c-statistics ranging from 0.796 to 0.803) had significantly better performance than weighted Charlson comorbidity scores (c-statistics ranging from 0.786 to 0.790). Conclusions were similar when using AIC values to assess model fit. Conclusion: The individual comorbidities in the Elixhauser were the most accurate in predicting in-hospital death. If the weighted score needs to be used due to sample size limitations, we found that the Elixhauser-Thompson score was the most accurate in this training set. While statistically significant, the magnitude of predictive accuracy gained by adding covariates to the model for in-hospital mortality were small. Future research should investigate the utility of a customized COVID-19-specific comorbidity score in predicting mortality among adults hospitalized with COVID-19.

COVID-19 and Kawasaki Disease: Novel Virus and Novel Case.

In the midst of the coronavirus disease 2019 (COVID-19) pandemic, we are seeing widespread disease burden affecting patients of all ages across the globe. However, much remains to be understood as clinicians, epidemiologists, and researchers alike are working to describe and characterize the disease process while caring for patients at the frontlines. We describe the case of a 6-month-old infant admitted and diagnosed with classic Kawasaki disease, who also screened positive for COVID-19 in the setting of fever and minimal respiratory symptoms. The patient was treated per treatment guidelines, with intravenous immunoglobulin and high-dose aspirin, and subsequently defervesced with resolution of her clinical symptoms. The patient's initial echocardiogram was normal, and she was discharged within 48 hours of completion of her intravenous immunoglobulin infusion, with instruction to quarantine at home for 14 days from the date of her positive test results for COVID-19. Further study of the clinical presentation of pediatric COVID-19 and the potential association with Kawasaki disease is warranted, as are the indications for COVID-19 testing in the febrile infant.