Families prefer in-person visits to telehealth for pediatric weight management during the pandemic

Background: The COVID-19 pandemic has presented multiple challenges to families participating in pediatric weight management programs (PWMP) and to medical providers in accessing and offering care. To accommodate patient/family needs our PWMP turned to telehealth exclusively early in the COVID-19 Pandemic. After in-person clinic visits were reestablished, telehealth was offered as an alternative option. The purpose of this study was to compare whether families chose in-person or telehealth visits when both options were available during the pandemic. Methods: A retrospective review of patient visits was analyzed from July 1, 2020, through December 31, 2020, of all visits to our PWMP. During this period, families were given the option of scheduling in-person clinic visits in our PWMP or being seen by telehealth for both new and follow- up visits. Families could be seen by a doctor, dietitian, and exercise physiologist at both types of visits. Descriptive statistics, frequencies, and percentages, for patient demographics and visit type, were determined, and associations were analyzed using logistic regression. Results: There were 1356 completed PWMP visits, with 977 (72.1%) done in-person and 379 (27.9%) by Telehealth. Patients had a mean age of 12.5 years, were 51.2% female, 51.9% White, 28.8% Black, 10.2% Hispanic, and 64.5% had Medicaid. The age of telehealth patients was greater (12.9 years versus 12.3 years, P = 0.041), and the percentage of follow-up visits was greater (81.5% versus 65.5%, P < 0.0001). There was no significant difference in race/ethnicity or insurance type. Telehealth was selected more often for follow-up visits compared to new visits [odds ratio (OR) = 2.052, P = 0.008]. Compared to White patients, Black patients selected Telehealth more often (OR = 1.371;P = 0.03) whereas Hispanic patients did not (OR = 0.819;P = 0.412). Conclusions: A solid majority of families choose in-person visits over telehealth when given the opportunity during the COVID-19 Pandemic. Factors favoring telehealth were being Black and having a follow-up visit. While telehealth increases flexibility and increases options to families, in-person clinic visits seem to be preferred especially for an initial visit.

A UNIQUE CASE OF XANTHOMATOSIS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Hypertriglyceridemia (TGL) is the abnormal concentration of triglycerides in the blood associated with atherosclerosis. It is known to cause skin lesions when the blood levels are more than 3000 mg/dl. It is also associated with 1 to 10 percent cases of acute pancreatitis and 10 to 20 percent when levels are higher than 2000 mg/dl. CASE PRESENTATION: A 36-year old morbidly obese man with medication non-compliance was evaluated by a dermatologist via a video tele visit due to COVID19 Pandemic. He has a history of uncontrolled IDDM, hypertriglyceridemia status post plasmapheresis a year ago associated with pancreatitis. He has no family history of hypertriglyceridemia. He reported rashes on his forearms and thighs for 3 weeks and was advised to go to the Emergency Department to rule out cutaneous manifestation of his underlying conditions. He initially reported epigastric pain radiating to his back, but his lipase and CT abdomen were negative for pancreatitis. He was vitally stable, and his exam was significant for yellowish papules on his forearms, legs bilaterally with erythematous borders. Labs: TGL 1618, total cholesterol 647, Glucose 223, A1c 12.6%, no Anion Gap.Imaging: Splenomegaly with Hepatic Steatosis likely due to TGL deposition.Patient was placed on Insulin drip to prevent pancreatitis and was started on fenofibrate, fish oil and rosuvastatin. Kept NPO initially with dextrose infusion to increase insulin drip & metabolize the triglycerides. Triglycerides gradually improved, and insulin drip was d/c. Shave Biopsy confirmed Eruptive Xanthoma. DISCUSSION: Eruptive xanthomas are characterized by an eruption of yellowish skin papules, encircled by an erythematous halo, most commonly arising over the extensor surfaces of the extremities, buttocks and shoulders in the setting of high triglyceride levels secondary to diabetes, diet or familial causes. The lipid deposits in these xanthomas are derived from circulating plasma lipoproteins. CONCLUSIONS: This case was unique as our patient developed eruptive xanthomas even at TGL level under 2000 mg/dl which is rarely seen. Clinically diagnosing Xanthomas are extremely important in order to treat hypertriglyceridemia in order to prevent pancreatitis, which has a grim prognosis. It is also important for reducing CAD risk. Xanthomas should be evaluated to prevent pancreatitis and long-term cardiac events rather than the lipid deposit itself. They can also be the only signs of underlying metabolic diseases like diabetes. Management should include pharmacological agents, counseling for compliance, nutrition & lifestyle modifications. All these patients with high TGLs will benefit from E3/E4 genotype testing as it is associated with higher cardiac disease and low response to statins. REFERENCE #1: Severe hypertriglyceridemia presenting as eruptive xanthomatosisSameera S Vangara, Kyle D Klingbeil, Raymond M Fertig, Jason L RadickDepartment of Internal Medicine, University of Miami Miller School of Medicine, Florida, USA REFERENCE #2: Eruptive Xanthomas as a cutaneous Manifestation of HypertriglyceridemiaA Case ReportMichael Digby, Md, Robert Belli, MS, Timothy McGraw, and Abigail Lee, MD DISCLOSURES: no disclosure on file for Moses Bachan;no disclosure on file for Zinobia Khan;No relevant relationships by Robert Siegel, source=Web Response No relevant relationships by Goutham Talluri, source=Web Response

COVID-19 INFECTION AND DRASTIC DECREASE IN CD4

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: It is well known now that COVID-19 cause lymphopenia. In the retrospective study the number of total T cells, CD4+ and CD8+ T cells were dramatically reduced in COVID-19 patients, especially in patients requiring Intensive Care Unit (ICU) care. (1) Lymphopenia and drastic reduction of CD4+ T cell counts in COVID-19 patients have been linked with poor clinical outcome too. (2) We present a case of a patient with well controlled HIV infection with stable absolute CD4 count but significant drop during COVID infection CASE PRESENTATION: A 67 year-old-man with history of HIV on ARV therapy with undetectable viral load, panhypopituitarism with central hypothyroidism, adrenal insufficiency and hypogonadism, recurrent DVT/PE on AC therapy, BPH, overactive bladder, stable angina presented with 3 days of fever, chills, diarrhea and malaise to ER. He received first dose of Moderna vaccine 2 weeks before admission. VS -saturation 79% on RA, and 96% on NRB mask, HR 122 beats/min, BP 159/87 mmHg, RR 18/min, T 101. PE unremarkable. Labs: Covid PCR +, WBC 15.3 K/cmm, ferritin 585.8 ng/ml, LDH 489 U/LAST 122 U/l, ALT 100U/L, CRP quant 321 mg/L, D dimer 1287 D-DU ng/ml, HIV RNA quant undetectable, CD4 67 cell/Ul, previous CD4 568 cmm 2 weeks prior admission. CXR:b/l patchy infiltrates. He was treated with dexamethasone, therapeutic Lovenox and received 1 U of convalescent plasma. His oxygen saturation improved, overall course was uneventful and patient was discharged home. CD4 count improved to 523 cmm 2 months later. DISCUSSION: It is shown that HIV infection does not increase the occurrence of COVID-19 and there is no increase in morbidity and mortality (2). The exact influence of COVID-19 on absolute T4 cells subset in HIV and their significance is presently unknown. Our patient had stable absolute CD4 count for years. He was compliant with ART and HIV viral load was undetectable. However, there was a drastic decline in his CD4 count that occurred during an acute COVID infection although he was on the same medications. CD4 recovered to baseline after COVID infection resolved. CONCLUSIONS: This is a unique case with such a dramatic drop of absolute CD4 count in acute COVID infection and further investigation on CD4 cells and it effects on HIV infection will need to be studied. REFERENCE #1: Diao B, Wang C, Tan Y, et al. Reduction and Functional Exhaustion of T Cells in Patients With Coronavirus Disease 2019 (COVID-19). Front Immunol. 2020;11:827. Published 2020 May 1. doi:10.3389/fimmu.2020.00827 REFERENCE #2: Peng Xiaorong, Ouyang Jing, Isnard Stéphane, Lin John, Fombuena Brandon, Zhu Biao, Routy Jean-Pierre, Sharing CD4+ T Cell Loss: When COVID-19 and HIV Collide on Immune System, JOURNAL=Frontiers in Immunology VOLUME=11, YEAR=2020, PAGES=3307, URL=https://www.frontiersin.org/article/10.3389/fimmu.2020.596631 DOI=10.3389/fimmu.2020.596631, ISSN=1664-3224 DISCLOSURES: no disclosure on file for Moses Bachan;no disclosure on file for Zinobia Khan;No relevant relationships by Mirjana Petrovic Elbaz, source=Web Response No relevant relationships by Robert Siegel, source=Web Response

Variant selection, characterization, and impact on antibody SARS-CoV-2 neutralization

Background: Monitoring genomic variation of SARS-CoV-2 is crucial in mitigating adaptation to the human host and developing effective treatments that safeguard global health. Bamlanivimab and etesevimab are monoclonal antibodies (mAbs) that have demonstrated potent SARS-CoV-2 neutralizing activity in both pre-clinical and clinical settings and have distinct but overlapping binding sites. Here, the selection and characterization of variants in a pre-clinical setting is presented alongside the impact of emerging variants on antibody binding affinity and viral neutralization potency. Methods: Variant selection was carried out via directed evolution of the receptor binding domain (RBD) and serial passage of authentic SARS-CoV-2 in the presence of bamlanivimab and etesevimab individually or in combination. Sequence confirmed, putative-resistance variants identified in both selection methodologies were incorporated into different assessment platforms (VSV-based SARS-CoV-2 pseudovirus neutralization, a yeast RBD display hACE2 competition, and binding affinity to mAb and hACE2) to evaluate potency loss of the selecting mAb and test activity against the mAb combination. Results: Serial passage of SARS-CoV-2 and directed evolution of the RBD protein were unable to select for resistant viral variants under the pressure of mAb combination therapy. In the same experimental paradigm, variants were identified when each mAb was evaluated alone (E484D/K/Q, F490S, Q493R, and S494P for bamlanivimab and K417N, D420N and N460K/S/T/Y for etesevimab). Neutralization and binding assessments confirmed reduced susceptibility of the variants to the single selecting mAb with 50-fold or greater reductions in potency. Importantly, aside from the Q493R variant, all other resistant viruses were neutralized by the mAb combination therapy. Conclusion: In vitro selection studies using single mAbs, bamlanivimab or etesevimab, identified key positions within the SARS-CoV-2 S-protein that have potential for viral resistance in the clinic, whereas similar studies with the mAb combination therapy were unable to select variants. Binding and competition assays confirmed the neutralization phenotyping data and indicates the mechanism of resistance is due to a reduction in binding affinity. The preclinical selection and functional characterization of resistant viral variants directly supports the observation that mAb combination therapy results in a lower frequency of treatment-emergent resistance in clinical treatment studies.

CASE OF PULMONARY FIBROSIS FROM COVID PNEUMONIA

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Coronavirus disease 2019 (Covid-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a devastating ongoing global pandemic. Its disease severity ranges from asymptomatic, mild to severe disease, which can be complicated by developing hypoxemic respiratory failure and acute respiratory distress syndrome (ARDS). Pulmonary fibrosis is condition that occurs due to scarring of lung tissue. Most common cause being idiopathic occurring over a long period of time but it can also occur several days after severe bacterial pneumonias due to activation of fibroblasts. Our case shows that Covid-19 infection can acutely cause pulmonary fibrosis. CASE PRESENTATION: A 76-year old woman, life time non-smoker, with a history of well controlled intermittent asthma (rescue inhaler only) never hospitalized for any exacerbations. She was transferred to our facility due to persistent oxygen requirements after diagnosed with Covid-19 pneumonia. She presented to an outside hospital 3 months prior with fever and shortness of breath. Her course was complicated with hypoxemia requiring oxygen via non-rebreather mask, bilateral lower extremity deep vein thrombosis requiring apixaban. Her oxygen requirement slowly improved to 2 liters via nasal cannula. Despite clinically improvement she became oxygen dependent. She failed weaning off oxygen multiple times. CT of her chest even showed predominant upper lobe scarring. She was discharged home with oxygen 5 months after her Covid-19 pneumonia diagnosis. DISCUSSION: Pulmonary fibrosis leads to lung scarring. Fibrotic tissue is dead tissue, no gas exchange happens and there is a restrictive pattern on Pulmonary function tests (PFTs). There are many different conditions that can lead to pulmonary fibrosis but it is not common to develop post viral infections. Classic Covid-19 pneumonia causes diffuse bilateral infiltrates causing severe inflammatory response leading to macrophage activation, cytokine release with activation and proliferation of fibroblasts causing tissue destruction and scarring. Except for well controlled intermittent asthma our patient did not have any underlying lung etiologies that could make her oxygen dependent. She is a life time non-smoker, no occupational exposure to any chemicals, pollutants, toxic fumes etc., no history of autoimmune diseases or connective tissue diseases, no radiation exposure, no usage of any pulmonary toxic medications like amiodarone, bleomycin. Review of old medical records and imaging did not show any evidence of pulmonary fibrosis. Unfortunately, there were no post Covid-19 PFTs available for comparison. CONCLUSIONS: Covid-19 pneumonia with diffuse bilateral infiltrates can rapidly progress into pulmonary fibrosis due to severe inflammatory response/cytokine storm (post-COVID fibrotic ARDS), which made our patient oxygen dependent with significant reduction in her quality of life. Reference #1: Belloli EA, Beckford R, Hadley R, Flaherty KR. Idiopathic non-specific interstitial pneumonia. Respirology. 2016 FEb.21(2): 259-68 Reference #2: Zhu N Zhang D Wang W et al.A novel coronavirus from patients with pneumonia in China, 2019.N Engl J Med. 2020;382: 727-733 DISCLOSURES: No relevant relationships by Moses Bachan, source=Web Response No relevant relationships by Zinobia Khan, source=Web Response No relevant relationships by swetha Nadella, source=Web Response No relevant relationships by Robert Siegel, source=Web Response No relevant relationships by Vijaya Vudathaneni, source=Web Response

FATAL CASE OF ACUTE CVA IN A YOUNG PATIENT DUE TO COVID-19

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Coronavirus disease 2019 (COVID-19) is an illness caused by Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2). In late 2019 and 2020 it had become a global pandemic, still ongoing severe morbidity and mortality throughout the world. It usually presents with fever, respiratory symptoms, GI symptoms like most viral prodrome. This disease severity can range from asymptomatic, mild to severe. It has a very complex pathophysiology which is still under investigation and yet to be understood. Our case shows us one of the rare scenarios that covid-19 presentation. CASE PRESENTATION: A 41-year-old man with history of seizure disorder, DM-2 and Depression presented to ED via EMS due to acute AMS x 1 day. He started sleeping more, not eating, confused, became non-verbal and only responded by opening eyes. He remained afebrile, tachycardic 115, Normotensive, O2 saturation of 94% on 2l of nasal cannula. On PE: non-verbal, not following commands, responds only to pain, had right facial droop, R- sided hemineglect and L- gaze tendency with R- arm plegia. NIHSS score was >12. Initial CTH - acute L-frontal, parietal, temporal, occipital and basal ganglia infarcts with large calcified plaque in L- Internal carotid artery terminus. Covid swab positive, labs: lymphopenia 5.9, ferritin 1421, LDH 403, D-dimer 620, CRP 54. CXR showed b/l infiltrates. He was above window period for TPA and received ASA and atorvastatin. MRI of brain showed L-PCA infarct and patchy MCA infarct;MRA L- Internal carotid artery thrombosis with visualization of L-MCA via collateral flow and severe flow restriction to distal left PCA. He was made DNR/DNI with supportive care but progressively worsen with increasing oxygen requirement and dies in 2days. DISCUSSION: Individuals with covid-19 has been presenting with number of coagulation abnormalities. Most likely by causing venous stasis, endothelial damage and hypercoagulable state by changing the circulating prothrombic factors, leading to thromboembolic events. But as of now, it is very unpredictable to assess who is at risk and what symptoms. Even though Elevated D-dimer correlates with increased risk of hypercoagulability some patient with slightly elevated D-dimer can present with massive thrombo-embolic events. CONCLUSIONS: In contrast with traditional presentation, this severe life-threatening viral infection, can involve multi-organs and can cause serious conditions like massive stroke with irreversible neurological damage even in young adults. Professionals and general population must be made aware of this rare presenting symptom, which will help to seek early medical attention. Reference #1: Oxley T, et al "Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young" New England Journal of Medicine 2020;DOI: 10.1056/NEJMc2009787. DISCLOSURES: No relevant relationships by Moses Bachan, source=Web Response No relevant relationships by Krishna Kamineni, source=Web Response No relevant relationships by Zinobia Khan, source=Web Response No relevant relationships by swetha Nadella, source=Web Response No relevant relationships by Robert Siegel, source=Web Response No relevant relationships by Vijaya Vudathaneni, source=Web Response