Evolution in Infectious Causes of Death in Liveborn Children in a Major Tertiary Children's Hospital: A Retrospective Autopsy Review of over 1200 Cases

Background: Infections have historically been a leading cause of death, particularly in children. Medical advances, including vaccines and antimicrobials, have significantly decreased infection-related deaths, but infections remain a cause of pediatric mortality, especially in premature infants. The types of infections implicated in childhood deaths have changed with these advances, for example, meningitis and meningococcal infections were leading causes in 1981 but not in the later period. The incidence and etiologies of infection- related deaths may be altered by major events that modify not only medical practices but also societal attitudes and activities. Examples of such events include the HIV/AIDS epidemic that began in the early 1980s and the more recent COVID-19 pandemic. In order to investigate changes in infection-related pediatric deaths over time, we analyzed and compared autopsy cases performed during 5-year span prior to both the HIV/AIDS epidemic and the COVID-19 pandemic in which infections contributed to death. Method(s): Review of all autopsy cases performed at our institution between 1/1/1975-1/1/1980 and between 1/1/2015-1/1/2020 was performed to identify cases in which infection directly contributed to death, comprising 1262 cases. Only liveborn children were considered, and neonatal sepsis from amniotic sac infections was excluded. Comparison of decedent characteristics and infectious etiologies between the two time periods was performed, identifying age, race, sex, gestational age (for decedents less than 3 months of age), and etiologic class of agent (bacterial, viral, fungal or parasitic). TORCH infections and vaccine-preventable illnesses were specifically assessed. Proportions were compared using 1 (assessing TORCH, vaccine-preventable, and prematurity deaths)- or 2-tailed (all others) z-tests, with significance calculated at the < 0.05 level. Result(s): In the 1970s cohort, 300 infectious autopsy cases were identified in liveborn children;73 were identified in the 2010s. Compared to the 2010s cohort, the 1970s decedents were more likely to be white (85% v 53%, p=0.012), comprise children aged 1-5 and 13+ (22% v 6.8% [p=0.003] and 16.4% v 8.3% [p=0.036]), and were less likely to be premature (66.7% v 80.4%, p=0.039). Vaccine-preventable illnesses (for example: measles) accounted for 36 deaths in the 1970s cohort but only 2 in the 2010s cohort (p=0.009). Thirteen children died of TORCH infections (CMV, toxoplasmosis and HSV) versus 5 in the 2010s (CMV and HSV), which did not reach statistical significance. Conclusion(s): Pediatric mortality secondary to infections has decreased significantly compared to fifty years ago, especially in younger children and in relation to vaccine-preventable infections such as meningococcal disease. This drop is largely attributed to medical advances, including vaccines and antimicrobial medications. Additional contributing factors could include practices adopted post-HIV/AIDS, especially in the community. Further exploration of how such changes in medical and social practice impacted mortality and comparing them to changes occurring in the intra/post-COVID-19 era, is helpful. Yet, with the increased survival of premature infants, they remain at risk of devastating consequences from infections.

Delta variant neutralizing antibody response following maternal COVID19 vaccination

Objective: To evaluate whether COVID19 vaccination during pregnancy confers immunological response to SARS-CoV-2 Delta variant. Study Design: Prospective cohort study of pregnant patients who had received any available COVID19 vaccine. Maternal and umbilical cord serum was collected at delivery. SARS-CoV-2 neutralization was measured with spike-pseudotyped viruses in HEK-293T-ACE2 cells as a function of reduction in Luc reporter activity using an env-deficient lentiviral system to produce viral particles pseudotyped with the B1.617.2 (Delta variant) spike. Neutralization titers represented the serum dilution at which relative luminescence units (RLU) were reduced by either 50%(ID50) or 80%(ID80) compared with virus control wells. RLU threshold for detection was 20. Result(s): Maternal and neonatal umbilical cord samples were collected from 20 individuals who received COVID19 vaccination during pregnancy. Most (n=16, 80%) received Pfizer, 2 Moderna, 2 Johnson&Johnson. One individual (5%) was vaccinated in first trimester, 11(55%) in second trimester, and 8(40%) in third trimester). Most individuals had detectable levels of neutralizing antibodies to SARS-CoV-2 Delta variant in maternal (n=15, 75%) and neonatal (n=17, 85%) serum. (Figure) No significant difference between maternal and neonatal serum titers. Conclusion(s): COVID19 vaccination during pregnancy yields an immunologic response in maternal serum that results in circulating neutralizing antibodies against SARS-CoV-2 Delta variant in maternal and neonatal serum at delivery. Disclosure: No [Formula presented] Copyright © 2022

Rural disparities in oncology patient portal enrollment and use

Background: Patient portals support patient access, engagement, and care coordination, yet could also widen the digital divide and exacerbate disparities among vulnerable populations. There is emerging evidence that racial/ethnic minority patients are less likely to use portals, yet prior research has not examined potential rural differences. We identified sociodemographic factors associated with portal enrollment and use among a racially and geographically diverse population of cancer patients. Methods: We retrospectively examined portal enrollment and use at an NCI-designated comprehensive cancer center from January 2015 until February 2022 among patients 18+ years old with a neoplastic disease diagnosis (ICD-10-CM C00-D49). Potential predictors included gender, race/ethnicity, marital status, age, rural (Rural-Urban Continuum Codes [RUCC] 4-9) vs nonrural (RUCC 1-3) residence, residential distance from the cancer center, and time since diagnosis. We used multivariable logistic regression to generate odds ratios (ORs) for portal enrollment and having ever sent a portal message, and Poisson regression to determine incidence rate ratios (IRRs) for number of logins and number of healthcare team interactions (portal messages or appointment requests), controlling for ICD-10 diagnosis (SAS 9.4). Results: We identified 11,333 patients (average age 67 years, 59% female, 24% rural, 10% Non-Hispanic Black, 1% Hispanic, 20% non-melanoma skin cancer, 14% breast cancer, 9% lung cancer). 36% of patients had enrolled in the portal, and of these, 80% had sent at least one message. Patients logged in a median of 203.5 times and had a median of 19 portal interactions. Rural residents were less likely to enroll in the portal than urban patients (28% vs 38%, p < 0.0001). Non-Hispanic Black patients and Hispanic/Latinx patients were less likely to enroll in the portal compared with non-Hispanic White patients (22% and 27%, respectively, vs 38.5%, p < 0.0001). Women, younger patients, more recently diagnosed cancer patients, and patients who were married/ partnered were significantly more likely to enroll. In multivariable analysis controlling for cancer type, rural patients were half as likely to enroll in the portal (OR: 0.48 [0.43-0.54]). Among those enrolled, rural residents were 25% less likely to have ever sent a portal message (OR: 0.75 [(0.62-0.92]), and had nearly half the login and interaction rates (IRR: 0.66 [0.66-0.67];IRR: 0.58 [0.58-0.59], respectively). Patients who were Non-Hispanic Black, Hispanic, or unmarried were also significantly less likely to enroll or engage in the portal. Conclusions: Patient portals remain underutilized among cancer patients, despite an increased reliance on virtual communications in the COVID era. Interventions to support portal engagement among rural residents and racial/ethnic minority patients are needed to avoid potentially exacerbating health disparities.

COVID-19 Vaccination Among Individuals With Inflammatory Bowel Disease: Perception, Efficacy, and Safety

The COVID-19 pandemic, caused by SARS-CoV-2, has been the most significant global health crisis of the past century. The development of safe and effective vaccines has led to a reduction in COVID- 19-related hospitalizations and deaths;however, the clinical trials that led to US Food and Drug Administration Emergency Use Authorization and/or approval of the vaccines in the United States did not include individuals with inflammatory bowel disease (IBD). Because individuals with IBD are commonly treated with immunosuppressive medications, there had been concern for reduced vaccine efficacy in this population. This article provides an overview of the peer-reviewed literature addressing COVID-19 vaccination in individuals with IBD;details the perceptions of patients with IBD of COVID-19 vaccines, including how gastroenterologists can help to reduce vaccine hesitancy;and describes the humoral immune response to COVID-19 vaccines, with a majority of patients with IBD seroconverting following complete vaccination regardless of medication exposure. Additionally, low rates of IBD flare and similar rates of vaccine-related adverse events to those in the general population are described. Finally, the article provides current recommendations from the Centers for Disease Control and Prevention for COVID-19 vaccination in individuals with IBD.

STRONG HUMORAL IMMUNE RESPONSE TO SARS-COV-2 VACCINE ADDITIONAL DOSE AMONG PATIENTS WITH INFLAMMATORY BOWEL DISEASES

Background: Current recommendations in many countries support additional COVID-19 vaccine doses in patients with inflammatory bowel disease (IBD) who are treated with immunosuppressants, yet real-world data on the effectiveness and safety of additional vaccine doses is lacking. We sought to quantify the humoral immune response to an additional (third) dose of mRNA vaccines in adolescents and adult patients with IBD. Methods: We performed a direct-to-patient, internet-based cohort study of patients with IBD in the United States who have received any SARS-CoV-2 vaccine granted EUA. Participants completed baseline and follow-up surveys and had blood work obtained approximately 8 weeks following completion of the initial vaccination series and 6 weeks following administration of an additional (third) vaccine dose. We performed quantitative measurement of antireceptor binding domain (RBD) IgG antibodies specific to SARS-CoV-2 using the LabCorp Cov2Quant IgG™ assay. Results: A total of 659 participants were included [415 participants (63%) initially received BNT162b2, 243 participants (37%) initially received mRNA-1273, and 5 participants (1%) initially received Ad26.COV2.S]. Demographic, clinical, and treatment characteristics of the study population are provided in Table 1. Over 98% of those receiving an initial mRNA vaccine received the same type additional dose. Whereas 93% had detectable antibody after the initial vaccination series, 99.5% had detectable antibodies following an additional dose. Mean (SD) increase in antibody level was 61 ug/mL (103) in those receiving BNT162b2 and 78 ug/mL (143) for those receiving mRNA-1273 (Figure 1). Importantly, of 47 of patients without initial antibody response, 45 (96%) had detectable antibodies following an additional dose. Additional vaccination was generally well tolerated in this population, with 44%, 24%, 25%, and 6% reporting no, mild, moderate, and severe side effects respectively. Discussion: These findings demonstrate robust immunogenicity to additional doses of SARS-CoV-2 vaccine, even amongst patients with undetectable antibody following the initial series. Adverse event rates were low. These data can be used to inform vaccine decisions in patients with a broad array of immune-medicated conditions frequently managed by immunosuppression. (Table Presented) (Figure Presented)

More to Do than Can Ever Be Done: Reconciling Landry Online Learning Objects with WCAG 2.1 Standards for Accessibility

The COVID-19 pandemic has accelerated a long-term trend in libraries toward the generation of online teaming objects. These materials in the library space are unique compared to those generated in other fields, as libraries frequently make them available for access on their website, or through library-owned social media channels, in formats meant to be available to all. This article looks at major types of library online learning objects and surfaces the most impactful areas of work for librarians and other education professionals interested in improving accessibility and accessibility compliance. The article and discussion are meant to provide an overview of critical WCAG 2.1 standards in relation to learning object types to make the practical implementation of accessibility less overwhelming. To supplement these recommendations, the authors have provided exhaustive lists of WCAG 2.1 criteria applicable to each learning object in the Appendixes.

Strong Response to SARS-CoV-2 vaccine additional doses among patients with inflammatory bowel diseases

Background: Current recommendations in many countries support additional COVID-19 vaccine doses in patients with inflammatory bowel disease (IBD) who are treated with immunosuppressants, yet real-world data on the effectiveness and safety of additional vaccine doses is lacking. We sought to quantify the humoral immune response to an additional vaccine dose in patients with IBD. Methods: We performed a direct-to-patient, internet-based cohort study of patients with IBD in the United States who have received any SARS-CoV-2 vaccine granted EUA. Participants completed baseline and follow-up surveys and had blood work obtained approximately 8 weeks following completion of the initial vaccination series and 6 weeks following administration of an additional vaccine dose. We performed quantitative measurement of anti-receptor binding domain (RBD) IgG antibodies specific to SARS-CoV-2 using the LabCorp Cov2Quant IgG™ assay. Results: A total of 659 participants were included [415 participants (63%) initially received BNT162b2, 243 participants (37%) initially received mRNA-1273, and 5 participants (1%) initially received Ad26.COV2.S]. Demographic, clinical, and treatment characteristics of the study population are provided in Table 1. Over 98% of those receiving an initial mRNA vaccine received the same type additional dose. Whereas 93% had detectable antibody after the initial vaccination series, 99.5% had detectable antibodies following an additional dose. Mean (SD) increase in antibody level was 61 ug/mL (103) in those receiving BNT162b2 and 78 ug/mL (143) for those receiving mRNA-1273 (Figure 1). Importantly, of 47 of patients without initial antibody response, 45 (96%) had detectable antibodies following an additional dose. Additional vaccination was generally well tolerated in this population, with 44%, 24%, 25%, and 6% reporting no, mild, moderate, and severe side effects respectively. Conclusion: These findings demonstrate robust immunogenicity to additional doses of SARS-CoV-2 vaccine, even amongst patients with undetectable antibody following the initial series. Adverse event rates were low. These data can be used to inform vaccine decisions in patients with a broad array of immune-medicated conditions frequently managed by immunosuppression.

Examining In-Person and Asynchronous Information-Seeking Behavior Instruction Among First-Year Engineering Students

This is a complete evidence-based practice paper. The current COVID-19 global pandemic has required educators to pioneer online instruction even as they deliver it. This shift has particularly impacted first-year programs, in which training engineering students to find reliable information is fundamental to their professional development and ABET and CEAB accreditation criteria. Typically, information seeking is taught in person so that instructors and librarians can directly observe and guide student behavior, a practice still evolving but well-established by research. However, the effects of online information-seeking training and the sudden transition on students' learning are very poorly understood. Even less is known about the use of asynchronous instructional methods. This paper significantly enhances existing knowledge by directly examining the efficacy of in-person and asynchronous online instructional modalities. For 60 students in a mandatory engineering-communication course, we deployed an enhanced online baseline-assessment exercise to understand students' existing information-seeking behavior. Librarians then deployed an asynchronous online lesson to teach engineering research practices, critical evaluation, and information literacy. We evaluated the extent to which the online lesson impacted student information-seeking behavior and compared it to existing data from the prior year's classroom version. Our results demonstrate that the asynchronous learning module significantly enhanced the students' critical evaluation of sources and student outcomes were comparable with results in the previous synchronous course. These results have dramatic implications for how we understand students' baseline information-seeking behaviors, pedagogical design to bring about meaningful changes in students' use of sources, and how course design can incorporate effective asynchronous online delivery in diverse models. © American Society for Engineering Education, 2021

Factors associated with cesarean section in patients with COVID

Objective: Experts have suggested that earlier delivery, even in non-severe cases, may be beneficial for patients with COVID, and that patients with COVID have higher rates of cesarean section. Factors associated with this increase are currently unclear. We sought to assess demographic and clinical factors associated with cesarean section (CS) in pregnant patients diagnosed with COVID. Study Design: Retrospective cohort of PCR-confirmed COVID positive pregnant patients in a single health system who delivered between March-December of 2020. Fetal death or planned CS excluded. Demographic data, pregnancy characteristics, and specifics of COVID infection ed and compared between patients who had vaginal delivery(SVD) and CS. Secondary analysis performed for symptomatic(sx) and asymptomatic(asx) patients separately. Bivariate statistics used to analyze the data. Multivariate Poisson regression performed to estimate adjusted relative risks. Results: Of 109 COVID positive patients, 19(17.4%) had planned CS. Of 91 with labor, 22(24%) had CS. CS was associated with overall BMI > 39.9(Table1). Non-private insurance and higher maternal age were associated with significantly higher rates of CS. Multiparity was not associated with SVD. Hypertensive disorders(PEC) of pregnancy and intraamniotic infection(IAI) were also associated with CS(Table 1). In regression analyses, symptomatic disease was associated with SVD [aRR 0.41, 95%CI 0.18, 0.93]. Relative risk of CS was 3-fold higher in patients with IAI[95% CI 1.6, 5.5], and 2.3-fold-higher in BMI > 39.9[95% CI 1.1, 5.0](Table2). Among sx patients, BMI > 39.9 was associated with 4-fold increase risk of CS;while in asx patients, IAI was associated with 4-fold increase risk of CS(Table 2). Maternal age and PEC were not associated with mode of delivery. Conclusion: Some known risk factors for severe and critical COVID, including higher BMI, were associated with CS in COVID positive pregnant patients. Symptomatic disease at time of delivery was more associated with SVD. [Formula presented] [Formula presented]

Preterm birth rates and race disparities pre and post COVID vaccination

Objective: The impact of 2021 vaccination and social restriction reversal on preterm birth (PTB) is unclear. We sought to compare the rates of PTB during the COVID pre- and post- vaccination periods with pre-pandemic rate. Study Design: Retrospective cohort comparing all deliveries over 20 weeks at a single tertiary center during ‘early’ COVID (ECOVID 3/2020-6/2020) vs. ‘late’ COVID (LCOVID 3/2021–6/2021), and LCOVID vs. pre-COVID (3-6/2014-2019). PTB < 37weeks, < 34weeks and < 28weeks were compared and stratified by race/ethnicity. Results: There were 20334 deliveries including 2647 ECOVID, 2114 LCOVID and 15574 pre-COVID. We noted 87 (0.03%) and 37 (0.02%) COVID infections in pregnancy during ECOVID and LCOVID, respectively. PTB rate during LCOVID (12.1%) was lower compared to ECOVID (14.5%), p=0.02. Rate of PTB < 34 was also lower during LCOVID (4.4% vs 5.7%, p=0.04). PTB < 28 did not differ (Table1). When controlling for prior PTB, LCOVID was associated with a decreased risk of PTB, adjusted odds ratio (aOR) 0.83[95% confidence interval (CI) 0.70, 0.99]. Among the small number of American Indian patients, PTB increased during LCOVID vs. ECOVID. There were no other significant differences based on race/ethnicity. Overall, PTB rates did not differ in LCOVID vs. pre-COVID. When stratified by race and ethnicity, White individuals had reduced PTB < 37 during LCOVID compared to pre-COVID, aOR 0.70 [95% CI 0.63, 0.99]. PTB rate was unchanged comparing LCOVID vs. pre-COVID in all other racial groups. Among small numbers of Hispanic Puerto Rican patients, PTB rate increased LCOVID vs. pre-COVID (Table 2). Conclusion: During 2021, PTB rates decreased from rates observed in 2020 at the height of COVID restrictions. Among White birthing individuals, PTB decreased in 2021 compared to pre-COVID rates. This decrease was not observed in Black and Hispanic birthing individuals. These data highlight the continued racially disparate impact of the COVID pandemic on PTB rates. [Formula presented] [Formula presented]

Humoral immune response after completion of covid-19 vaccine series among patients with ibd

Introduction: Individuals on immunosuppression were excluded from COVID-19 vaccine clinical trials which led to their emergency use authorization (EUA). As a result, patients with inflammatory bowel disease (IBD) who are frequently treated with immune suppressing medications have questions about COVID-19 vaccine effectiveness. Data of vaccine effectiveness and immune response in the IBD population are urgently needed to guide vaccination strategies. This study aimed to assess serologic response after completion of COVID-19 vaccine series in a large IBD population across the US. Methods: Partnership to Report Effectiveness of Vaccination in populations Excluded from iNitial Trials of COVID (PREVENT-COVID) is a prospective observational cohort study of IBD patients who received any COVID-19 vaccine granted EUA in the US. Enrolled participants had the option to provide serum samples to evaluate antibody development 8 weeks following completion of COVID-19 vaccine series. Quantitative analysis of anti-receptor binding domain (RBD) IgG antibodies specific to SARS-CoV-2 was performed using the LabCorp Cov2Quant IgG assay. Qualitative assessment of nucleocapsid antibodies as an indicator of past infection was also completed. This analysis included participants who completed vaccination series and laboratory testing prior to 6/17/ 21. Individuals who reported prior COVID infection and/or had positive nucleocapsid antibody were excluded. Descriptive statistics were performed to characterize the study population and antibody response. Results: A total of 788 participants with IBD (mean age 48 yrs, 73% female) were included, and 752/ 788 [95.4%, 95% confidence interval (CI) 93.7-96.7%] had detectable anti-RBD antibodies. Additional demographic characteristics and distribution of antibody response across medication classes are shown in Table 1. Antibody response was generally similar across age group, vaccine type, and IBD medication class (Figure 1);however, individuals receiving corticosteroids (n=35) had reduced antibody response with 85.7% (95% CI 70.6-93.7) having detectable antibodies vs 95.9% (95% CI 94.2-97.1) in non-steroid users. Conclusion: A vast majority of our IBD cohort including those on immunosuppressive therapies demonstrated humoral immune response after completion of COVID-19 vaccine series. Longer term data are needed to assess durability of antibody response, but this emerging data provides reassurance that most IBD medications do not significantly diminish response to COVID-19 vaccination.

256 Has the COVID-19 Pandemic Adversely Affected Measure of Burnout and Empathy in Emergency Medicine Residents?

Study Objectives: To determine the levels of burnout and empathy amongst EM residents during a time of pandemic as compared to the previous year. Methods: In June of 2020, three months into the COVID-19 pandemic and nearing the end of the academic year, EM residents in a suburban 4-year program were surveyed utilizing the Maslach Burnout Inventory (MBI) and the Jefferson Scale of Empathy (JSE). Surveys were presented online utilizing the Qualtrics® online platform. Anonymity was assured. At the time of this survey over 6000 patients had tested positive for COVID-19 in the hospital network. In one of the two hospitals, EM residents manage the care of the patients on the Intensive Care (ICU) service. Many participants had been required to work extra shifts and additional ICU months to cover the increased number of critical patients and to cover residents who could not work due to COVID-19 illness or exposure. These metrics were compared with matched historical data from second and third-year residents completing the survey one year previously. Results: A total of 54 of 57 residents responded to the survey for a response rate of 95%, however 7 declined to have their data used for research, giving us an analyzable response rate of 83% (28 males and 19 females). A total of 13 first-year, 9 second-year, 12 third-year and 13 fourth-year residents responded. The median age was 31 years (IQR 29-34). There was no difference by PGY year in the JSE score (range 20-140), average 108.0 (IQR: 99-117), p>0.05). There was also no difference by PGY year in any of the MBI categories. Emotional exhaustion scores revealed 31.9% high, 29.8% moderate, and 38.3% low levels. Depersonalization scores ranged from 38.3% high, 40.4% moderate and 21.3% low levels. Personal Accomplishment scores which are scored inversely (higher is better) ranged as follows: 19.2% high, 34% moderate and 46.8% low. Males were more likely than females (28.6% vs. 5.3%, p=0.01) to have high levels of Personal Accomplishment. Females were more likely than males to have (57.9% vs. 17.9%, p=0.01) moderate levels of Personal Accomplishment. Females [111 (IQR 103-123)] and males [106 (97-116)] had similar levels of empathy on the JSE;p=0.18. No significant difference was found in any of the four metrics measured when matched with the 15 residents who took the same survey in 2019;p>0.1 (see Table). Conclusion: As measured by commonly utilized metrics, EM residents in all years showed concerningly high or moderate levels of Emotional Exhaustion and Depersonalization (61.7% and 78.7%). Females and males demonstrated similar levels of empathy but females were less likely than males to have high Personal Accomplishment scores. Although these results, indicating high rates of burnout in EM residents, remain a concern, there is no evidence that the current pandemic has negatively impacted these metrics. [Formula presented]