Medical Knowledge Acquisition during a Pandemic: Pediatric Subspecialty in-Training Examination and Board Certification Exam Passing Rate.

OBJECTIVE: The COVID-19 pandemic resulted in training programs restructuring their curricula. Fellowship programs are required to monitor each fellow's training progress through a combination of formal evaluations, competency tracking, and measures of knowledge acquisition. The American Board of Pediatrics administers subspecialty in-training examinations (SITE) to pediatric fellowship trainees annually and board certification exams at the completion of the fellowship. The objective of this study was to compare SITE scores and certification exam passing rates before and during the pandemic. METHODS: In this retrospective observational study, we collected summative data on SITE scores and certification exam passing rates for all pediatric subspecialties from 2018 to 2022. Trends over time were assessed using analysis of variance (ANOVA) analysis to test for trends across years within one group and t-test analysis to compare groups before and during the pandemic. RESULTS: Data were obtained from 14 pediatric subspecialties. Comparing prepandemic to pandemic scores, Infectious Diseases, Cardiology, and Critical Care Medicine saw statistically significant decreases in SITE scores. Conversely, Child Abuse and Emergency Medicine saw increases in SITE scores. Emergency Medicine saw a statistically significant increase in certification exam passing rates, while Gastroenterology and Pulmonology saw decreases in exam passing rates. CONCLUSIONS: The COVID-19 pandemic resulted in restructuring didactics and clinical care based on the needs of the hospital. There were also societal changes affecting patients and trainees. Subspecialty programs with declining scores and certification exam passing rates may need to assess their educational and clinical programs and adapt to the needs of trainees' learning edges.

C-reactive Protein Elevation Is Associated With QTc Interval Prolongation in Patients Hospitalized With COVID-19.

Background: The relationship between inflammation and corrected QT (QTc) interval prolongation is currently not well defined in patients with COVID-19. Objective: This study aimed to assess the effect of marked interval changes in the inflammatory marker C-reactive protein (CRP) on QTc interval in patients hospitalized with COVID-19. Methods: In this retrospective cohort study of hospitalized adult patients admitted with COVID-19 infection, we identified 85 patients who had markedly elevated CRP levels and serial measurements of an ECG and CRP during the same admission. We compared mean QTc interval duration, and other clinical and ECG characteristics between times when CRP values were high and low. We performed mixed-effects linear regression analysis to identify associations between CRP levels and QTc interval in univariable and adjusted models. Results: Mean age was 58 ± 16 years, of which 39% were women, 41% were Black, and 25% were White. On average, the QTc interval calculated via the Bazett formula was 15 ms higher when the CRP values were "high" vs. "low" [447 ms (IQR 427-472 ms) and 432 ms (IQR 412-452 ms), respectively]. A 100 mg/L increase in CRP was associated with a 1.5 ms increase in QTc interval [ß coefficient 0.15, 95% CI (0.06-0.24). In a fully adjusted model for sociodemographic, ECG, and clinical factors, the association remained significant (ß coefficient 0.14, 95% CI 0.05-0.23). Conclusion: An interval QTc interval prolongation is observed with a marked elevation in CRP levels in patients with COVID-19.

Disparities in Telemedicine Success and Their Association With Adverse Outcomes in Patients With Thoracic Cancer During the COVID-19 Pandemic.

Importance: Disparities in access to telemedicine were identified at the onset of the COVID-19 pandemic, but the consequences of these disparities are not well characterized. Objective: To investigate factors associated with successfully accessing and completing telemedicine visits and the association between telemedicine visit success and clinical outcomes among patients with thoracic cancer. Design, Setting, and Participants: This retrospective cohort study included patients who attended outpatient visits at the thoracic oncology division of Johns Hopkins Medical Institute in Baltimore, Maryland, from March 1 to July 17, 2020. Main Outcomes and Measures: Associations of age, sex, race, ethnicity, insurance status, marital status, zip code, type of cancer, cancer stage, and type of therapy with telemedicine visit success (defined as completed visits with synchronous audio-video connection) and of visit success status with changes in therapy and odds of emergency department and urgent care visits, hospitalizations, and death were assessed using χ2 and Fisher exact tests and are reported as odds ratios (ORs). Results: A total of 720 patients and 1940 visits with complete data were included in the analysis; the median patient age was 65.7 years (range, 54.7-76.7 years), and 384 (53.33%) were male. Of the 1940 visits, 679 (35.00%) were in person and 1261 (65.00%) were telemedicine. Of the telemedicine visits, 717 (56.86%) were successful and 544 (43.14%) were unsuccessful. Patients who were Black (OR, 0.62; 95% CI, 0.41-0.95), had Medicaid (OR, 0.38; 95% CI, 0.18-0.81), or were from a zip code with an elevated risk of cancer mortality (OR, 0.51; 95% CI, 0.29-0.90) were less likely to have successful telemedicine visits than to have unsuccessful visits. Patients with at least 1 unsuccessful telemedicine visit had higher likelihood of an emergency department (OR, 2.73; 95% CI, 1.42-5.22) or urgent care (OR, 4.50; 95% CI, 2.41-8.41) visit or hospitalization (OR, 2.37; 95% CI, 1.17-4.80). Similarly, patients who had no successful telemedicine visits and for whom more than 1 telemedicine visit was scheduled had a higher likelihood of an emergency department (OR, 3.43; 95% CI 1.80-6.52) or urgent care (OR, 4.24; 95% CI 2.24-8.03) visit or hospitalization (OR, 4.19; 95% CI 2.17-8.10). Patients with all successful telemedicine visits (OR, 0.52; 95% CI, 0.30-0.90) or only 1, unsuccessful visit (OR, 0.32; 95% CI, 0.13-0.75) had lower odds of death compared with patients seen in-person only. Starting a new therapy was associated with lower odds of having a telemedicine visit vs an in-person visit (OR, 0.49; 95% CI, 0.37-0.64) and higher odds of a successful telemedicine visit vs an unsuccessful telemedicine visit (OR, 1.90; 95% CI, 1.28-2.82). Conclusions and Relevance: In this cohort study, patients with thoracic cancer who were Black, had Medicaid, or were from a zip code with a high risk of cancer mortality had increased odds of unsuccessful telemedicine visits compared with their counterparts and unsuccessful telemedicine visits were associated with worse clinical outcomes compared with successful visits. These findings suggest that more work is needed to improve telemedicine access for disadvantaged patients.

Markers of endothelial cell activation are associated with the severity of pulmonary disease in COVID-19.

Severe coronavirus disease-19 (COVID-19) is characterized by vascular inflammation and thrombosis. We and others have proposed that the inflammatory response to coronavirus infection activates endothelial cells, leading to endothelial release of pro-thrombotic proteins. These mediators can trigger obstruction of the pulmonary microvasculature, leading to worsening oxygenation, acute respiratory distress syndrome, and death. In the current study, we tested the hypothesis that higher levels of biomarkers released from endothelial cells are associated with worse oxygenation in patients with COVID-19. We studied 83 participants aged 18-84 years with COVID-19 admitted to a single center. The severity of pulmonary disease was classified by oxygen requirement, including no oxygen requirement, low-flow oxygen, high-flow nasal cannula oxygen, mechanical ventilation, and death. We measured plasma levels of two proteins released by activated endothelial cells, von Willebrand Factor (VWF) antigen and soluble P-Selectin (sP-Sel), and a biomarker of systemic thrombosis, D-dimer. Additionally, we explored the association of endothelial biomarker levels with the levels of pro-inflammatory cytokine and chemokines, and vascular inflammation biomarkers. We found that levels of VWF, sP-sel, and D-dimer were increased in individuals with more severe COVID-19 pulmonary disease. Biomarkers of endothelial cell activation were also correlated with proinflammatory cytokines and chemokines. Taken together, our data demonstrate increased levels of VWF and sP-selectin are linked to the severity of lung disease in COVID-19 and correlated with biomarkers of inflammation and vascular inflammation. Our data support the concept that COVID-19 is a vascular disease which involves endothelial injury in the context of an inflammatory state.

Malnutrition Increases Hospital Length of Stay and Mortality among Adult Inpatients with COVID-19.

BACKGROUND: Malnutrition has been linked to adverse health economic outcomes. There is a paucity of data on malnutrition in patients admitted with COVID-19. METHODS: This is a retrospective cohort study consisting of 4311 COVID-19 adult (18 years and older) inpatients at 5 Johns Hopkins-affiliated hospitals between 1 March and 3 December 2020. Malnourishment was identified using the malnutrition universal screening tool (MUST), then confirmed by registered dietitians. Statistics were conducted with SAS v9.4 (Cary, NC, USA) software to examine the effect of malnutrition on mortality and hospital length of stay among COVID-19 inpatient encounters, while accounting for possible covariates in regression analysis predicting mortality or the log-transformed length of stay. RESULTS: COVID-19 patients who were older, male, or had lower BMIs had a higher likelihood of mortality. Patients with malnutrition were 76% more likely to have mortality (p < 0.001) and to have a 105% longer hospital length of stay (p < 0.001). Overall, 12.9% (555/4311) of adult COVID-19 patients were diagnosed with malnutrition and were associated with an 87.9% increase in hospital length of stay (p < 0.001). CONCLUSIONS: In a cohort of COVID-19 adult inpatients, malnutrition was associated with a higher likelihood of mortality and increased hospital length of stay.