Complex presentations in people with diabetes: Does HbA1c help or hinder?

HbA1c measurement is widely used for diagnosis/ management/remission of diabetes with international schemes certifying comparability. A) 75 year-old Chinese female with type 2 diabetes was admitted in April 2020 with Covid-19 and diabetic ketoacidosis. Glucose was 35mmol/l and HbA1c 150mmol/mol with previous HbA1c of 45mmol/mol on metformin and alogliptin. She was treated for ketoacidosis and once-daily Lantus introduced along with supportive management of viral illness. B) 68 year-old Afro-Caribbean with type 2 diabetes on metformin before admission, presented with new onset, jerky ballistic movements of high amplitude in right arm, 10-15 movements every 5 min. Admission glucose was >33mmol/l, ketones 1.8mmol/l and HbA1c >217mmol/ mol. Hemichorea-hemiballism, a hyperglycaemia related movement was diagnosed and insulin commenced. Glucose decreased to 8-20mmol/ l, reaching 5-15mmol/ l by time of discharge. Ballistic movements resolved when glycaemic control improved with HbA1c 169mmol/mol, 25 days after discharge. C) Several days before admission, a female with diabetes over 20 years required attention from paramedics on four occasions for hypoglycaemia. Months beforehand metformin was replaced by gliclazide due to chronic kidney disease with HbA1c 50mmol/mol, and she was transfused six weeks before admission for microcytic anaemia. Gliclazide was discontinued and her diet modified which prevented further hypoglycaemic episodes. Variant haemoglobin, beta-thalassaemia which can overestimate glycaemia;undetected by HbA1c HPLC method, invalidated HbA1c as did the blood transfusion. These cases highlight that inadequate understanding of HbA1c can lead to acute presentations of dysglycaemia. As HbA1c accuracy can be affected by multiple factors, clinical assessment and triangulation are key to the management of such patients.

Ethnic Differences in Cancer Deaths at Home before and during Pandemic

Introduction Place of death is a metric used for planning and monitoring palliative care (PC). The COVID-19 pandemic has seen a significant increase in cancer deaths at home. Aims To determine whether pandemic increases in the percentage of cancer deaths at home differ by ethnic group Methods Data source: death registrations in England, 2018 to 2021 with underlying cause of death cancer (ICD-10 C00-C97). Ethnic group derived from linked hospital episode data. The age and deprivation distribution across ethnic groups varies and each has a strong independent effect on place of death. so, calculated percentage deaths at home were standardised by these factors to make them comparable. Analysis concentrated on the largest ethnic groups: White, Asian/Asian British (Asian), and Black/African/ Caribbean/Black British (Black). Comparisons were made between time periods by analysis of the ratio of percentages 2020-2021 (COVID-19 Pandemic) vs 2018-2019 (Baseline). Results For each ethnic group the age-standardised percentage of cancer deaths at home significantly increased (P < 0.05) from 2018-2019 to 2020-2021 . Asian: 33.5%, 47.5% . Black: 28.8%, 39.0% . White: 30.7%, 41.2% The ratio of standardised percentage of deaths at home (95% CI) was . Asian: 1.42 (1.36,1.48 ) . Black: 1.35 (1.27, 1.44) . White 1.34 (1.33, 1.35) Conclusions Cancer deaths at home increased by > 10 percentage points during the pandemic for Asians, Blacks and Whites. Significant differences between ethnic groups before the pandemic (2018-19) persisted with Asians more likely than Whites, and Blacks less likely than Whites to die at home. The largest increase was for Asians, the group with the highest pre-pandemic home deaths. Impact These ethnic differences merit investigation regarding cultural preferences, access issues and quality of PC experience. Community health and PC teams need additional resources and training in culturally sensitive care to support the increased number of ethnically diverse cancer patients dying at home.

Calcifying Epithelial Odontogenic Tumour - A Diagnostic Challenge

Introduction/Aims: Calcifying epithelial odontogenic tumour (CEOT) or Pindborg's tumour is a rare, benign, slow-growing dental neoplasm which is locally aggressive and can invade dentoalveolar bone with possible displacement of teeth and soft tissue. We present a case of CEOT, which was initially managed as cemento-osseous dysplasia (COD). Material(s) and Method(s): A 52-year-old Afro-Caribbean female presented with a two-month history of a left anterior maxillary swelling and examination revealed a firm, buccal mass from upper left central incisor to first premolar. Plain radiograph and computed tomography (CT) imaging revealed a dense calcified body with a lucent capsule measuring 19 x 24 x 23 mm causing displacement of adjacent teeth and expansion of the maxillary cortex, and concluded the diagnosis of COD. Biopsy was offered to the patient but she was reluctant to proceed, so she was managed conservatively according to the radiological diagnosis. Results/Statistics: During the 18-month surveillance period, the patient developed signs of infection of her anterior left maxilla and COD. CT scans showed a slight increase in the tumour size and surgical excision was postponed due to COVID-19 pandemic and resolution after oral antibiotics. After another 12 months, a biopsy of the bony mass was carried out due to overlying mucosal erythematous and nodular changes. The histology confirmed CEOT. Conclusions/Clinical Relevance: Radiological diagnosis is often helpful and tissue biopsy is key when adverse signs are detected. Clinicians should be aware of CEOT as a differential diagnosis for any slow-growing bony lesion which appears mixed radiolucent and radiopaque on imaging. Copyright © 2022

ASGBI Congress 2022

The proceedings contain 589 papers. The topics discussed include: robotic surgery for colorectal cancer: a single-center experience;Cecal volvulus: a district general hospital experience and review of the literature;'nurse led colorectal 2ww clinic': impact on early assessment and faster diagnosis of colorectal cancer;audit of pilonidal sinus surgery - our experience in a district general hospital Hamed Hajiesmaeili, Aida;major elective colorectal surgery at a non-acute site: is it safe or not?;an analysis of rectal cancer patient treatment and outcomes in a large NHS Trust;short term outcomes of patients undergoing transanal total mesorectal excision versus robotic low anterior resection;colonic polyps surveillance and outcomes - are we using a magnifying glass?;surgical simulation - does it improve the undergraduate surgical experience?;'learning lessons, inspiring change and driving improvements' - a review of morbidity and mortality meetings in general and vascular surgery;teaching to transform surgical culture: an educational program and thematic analysis in a general surgery department;examining the benefits of one-to-one African Caribbean mentoring for prospective medical students;and the nutritional management of emergency and elective surgical patients - are we doing enough in the COVID-19 pandemic?.

The Clinical Conundrum of Diagnosing Children with Fever and Pain Abdomen Amidst a Clustering of Pims-Ts Cases in the Omicron Dominant Era

Aims The Omicron variant of SARS-CoV-2 variant has rapidly spread in the UK since December 2021.There was a significant increase in the number of children testing positive for SARS-CoV-2 in December 2021 in the population served by this DGHS. A clustering of cases of PIMS- TS was noted in the last week of December 2021 and the first week of January 2022. The focus of this descriptive study of PIMS-TS patients from a single centre is to report the clustering of cases in the Omicron dominant period and to describe the dilemma of managing children who present with fever and pain abdomen. Methods Children confirmed to have PIMS-TS and one child who presented mimicking PIMS -TS were identified, their investigations, treatment and outcomes were reviewed Results A cluster of 6 children diagnosed as PIMS -TS presented from the 29th of December 2021 to the 8th of January 2022.The mean age of patients was 9.3 years. There was ethnic variation with 3 Asian, 2 Afro Caribbean and one White child. Mean CRP was 226( range 85-400). All children presented with fever of more than 3 days.3 children presented with partial Kawasaki features, 2 children were treated for shock and 2 children presented with pain abdomen and fever. A 15 year old presented with fever, pain abdomen and tenderness in the right iliac fossa. He was managed initially as appendicitis. Blood markers for PIMS-TS were significantly raised along with raised CRP of 204. CT abdomen showed ileitis. His NPA RT- PCR was positive for SARS-CoV-2. He continued to have high fever, a diagnosis of PIMS-TS was made. There was significant improvement in both clinical condition and biochemical markers following IV Methylprednisolone. On the same day a 11 year old presented with fever, pain abdomen and increased irritability. He had global developmental delay and was PEG fed. He was initially managed as PIMS-TS then diagnosed to have appendicitis. CT abdomen showed a perforated appendix. He had a good outcome after surgery Conclusion The clustering of cases of PIMS- TS may be specific to this geographical area and multi-ethnic population following a period of high SARS-CoV-2 prevalence in the community with the Omicron variant. PIMS-TS can closely mimic appendicitis and distinguishing between both can be difficult. In the first child, CRP was unusually high (202) which helped in making a diagnosis avoiding unnecessary surgery. In the second child clinical acumen and involvement of multiple specialist teams helped in making the diagnosis of appendicitis. The global developmental delay and the child being nonverbal proved to be confounding factors. Cases of PIMS-TS can have bowel inflammation, it is also possible that COVID-19 can occur with other pathologies. Radiology findings need to be interpreted with the clinical picture. Clinical acumen, considering a range of differentials working closely with other specialities enables us to make a correct diagnosis for the unwell child who presents in the COVID-19 pandemic.

Understanding barriers and facilitators to clinical trial participation among Black patients with multiple myeloma

Background: Currently, Black patients make up 20% of people living with multiple myeloma, yet they represent only 6% of participants in clinical trials.1 The underrepresentation of Black patients in clinical trials can contribute to outcome disparities thereby negatively impacting health equity in cancer treatment and outcomes.2 This project examined attitudes towards clinical trials among Black multiple myeloma patients and caregivers. Findings will inform the development of programs aimed at increasing clinical trial participation in this population. Methods: In 2021, the Cancer Support Community conducted an online survey to gain insights on barriers, facilitators, and perceptions of clinical trials among Black multiple myeloma patients and caregivers/care partners. Survey questions were informed by insights from prior focus groups. 94 patients and 101 caregivers were surveyed. Results: Most participants were male (62%) and African American (90%). 5% identified as African Caribbean and 5% as Black and Hispanic. The average age was 46 years. Just over half (51%) currently or previously participated in clinical trials. Of those who chose not to participate in a trial, the most common reasons were fear of side effects (46%) and fear of receiving a placebo (38%). Another barrier to participation reported was discomfort with being randomly assigned to a treatment (56%). Participants reported a significant level of distrust in medical research and doctors, saying that it was “very or somewhat likely” that doctors provide treatment as part of an experiment without patient consent (41%) and that they might be used as a “guinea pig” (25%). Of note, 57% of respondents said COVID had changed their attitude towards participating in clinical trials. 14 of 16 factors mentioned in our focus groups were affirmed by more than half of respondents as facilitating participation in a clinical trial. The top factors were: Understanding potential side effects (66%) My health care team speaks to me about trials (65%) Compensation offered for transportation, childcare, or time off work (62%) My family/community support my decision (61%). Conclusions: These findings are consistent with previous research which found that cancer patients reported the biggest attitudinal barriers to clinical trial participation were fear of side effects, distrust in medical research, and random assignment to clinical trial groups.3 Our study highlights that Blacks and African Americans living with multiple myeloma value multifactorial efforts to increase clinical trial participation: logistical and financial interventions, patient/provider communication, and culturally sensitive support and education programs. These programs can also work to improve health equity by reducing barriers to overall care and encouraging Blacks and African Americans living with multiple myeloma to be active members of their health care team.

PUBLIC VIEWS DURING THE CORONAVIRUS PANDEMIC: A UK BASED MIXED METHOD STUDY

Introduction: The coronavirus pandemic presents the greatest challenge to public health in living memory. To slow the spread of the virus the UK initiated periods of strict social distancing, or lockdown. The ongoing social and psychological impacts of the pandemic and lockdowns are still under investigation. We aimed to explore longitudinally the attitudes and behaviors of members of the UK public from the start of UK lockdowns in March, 2020. We focused on mental health, adherence to health behaviours and government regulations, perceptions of vaccinations, and impact on Black, Asian, Minority Ethnic (BAME) participants. Method: Focus groups (2-8 people, 60 min) and surveys were conducted with 57 UK residents from March 23, 2020 to the present at 5 different timepoints that captured lockdowns and firebreaks (93% retention). Participants were 51% Female, mean age 37.1 (Range: 20-60), 72% White, 5% Mixed or Multiple ethnic groups, 16% Asian or Asian British, and 7% Black, African, Caribbean or Black British. Surveys included the Patient Health Questionnaire - Somatic, Anxiety, and Depressive Symptoms (PHQ-SADS), the Capabilities, Opportunities, Motivations and Behaviours questionnaire (COM-B), and coronavirus specific questions such as vaccination intention. Qualitative results: The central theme was that of loss;'practical losses' e.g. income and 'psychological losses' e.g. motivation. Loss improved, but uncertainty and anticipatory anxiety continued across timepoints. Reported mental health issues improved over Summer 2020 and worsened in Nov 2020. Alert fatigue and learned helplessness emerged as the main themes at that time and marginalization by BAME participants. Behavioural adherence and vaccination uptake focused around perception of risk and community vs individual responsibility. Quantitative results: Data will be analysed following the current wave of data collection (Nov-Dec 2021) and will presented in March, 2022. Conclusion: Mental health fluctuated with the ability to socially connect with others outside of the household. Feelings of loss improved over time. Alert fatigue and general mistrust in government increased as did learned helplessness resulting in a loss of motivation. Results have had a significant policy and media impact in the UK and resulted in several publications to date.

WHO ACCESSES EMERGENCY HORMONAL CONTRACEPTION THROUGH AN ONLINE SEXUAL HEALTH SERVICE?

Introduction The COVID-19 pandemic has shifted services offered in clinic online, with some local authorities starting to offer Emergency Hormonal Contraception (EHC) through a sexual health e-service. After completing an online, asynchronous consultation, EHC could be delivered or collected in pharmacy. Method Retrospective analysis of 12,016 EHC consultations completed between 1st January 2021 and 31st December 2021, from 11 local authority areas in London. Age, ethnicity, and deprivation deciles were used to identify demographic trends. Results The majority of EHC consultations were completed by 25-34 year olds (41.0%, n=4922). 53.4% (n=6422) of consultations were completed by users from the bottom 3 deciles of deprivation. 74.6% (n=8967) of consultation were from racially minoritised groups. Amongst 16-17 year olds and 35-44 year olds, the majority of consultations were completed by users in the bottom 3 deciles of deprivation (58.5% (n=197) and 58.6% (n=495) respectively). 66.2% (n=1289) of Black African women were from the bottom 3 deciles of deprivation, as were 58.6% (n=1498) of Black Caribbean women and 46.4% (n=1416) of White British women. 53.1% (n=1033) of Black African women, 54.3% (n1388) of Black Caribbean women, and 47.1% (n=1435) of White British women, were 16-24 years old. Discussion The majority of individuals accessing online EHC are young and racially minoritised, experiencing significant levels of deprivation. This approach to helping users access online EHC could help reduce unintended pregnancies and mitigate health inequalities. Local authorities could consider whether an online EHC service would help in their local area.

AN ANALYSIS OF SERVICE USERS ACCESSING A ROUTINE CONTRACEPTION SERVICE VIA AN ONLINE PLATFORM DURING THE COVID-19 PANDEMIC

Introduction The COVID-19 pandemic has moved some health services, such as contraception, online. Eleven local authorities in London enrolled for a routine contraception (RC) e-service. After completing an online, asynchronous consultation, RC could be delivered or collected in pharmacy. Method Retrospective analysis of 10,525 RC consultations completed between 1st January 2021 and 31st December 2021, from 11 local authorities in London. Age, ethnicity and deprivation decile were used to identify demographic trends. Results The majority of RC consultations were completed by 25-34 year olds (47.9%, n=5042). The majority (61.2%, n=6442) of consultations were completed by users in the lower deciles 2-4. 66.7% (n=7021) of consultations were completed by users from ethnic minority groups. In 16-17 year olds and 35-44 year olds, the majority of RC consultations were completed by users in the bottom 3 deciles of deprivation (55.5% (n=146) and 55.8% (n=383) respectively). 68% (n=607) of Black African women were from the bottom 3 deciles of deprivation, as were 59.5% (n=606) of Black Caribbean women as compared to 40.6% (n1432) of White British women. 46.1% (n=412) of Black African women, 51.9% (n=576) of Black Caribbean women, and 45.5% (n=1595) of White British women, were 16-24 years old. Discussion The majority of individuals accessing RC online are young and racially minoritised, experiencing significant levels of deprivation. An online RC service can reach populations with the poorest sexual health outcomes, reduce unintended pregnancies and help reduce health inequalities. Local authorities could consider whether an online RC service would help in their area.

Service analysis examining the outcomes based on dexamethasone duration in Covid patients requiring oxygen in UKhospital

Background: Recent RECOVERY trial showed use of dexamethasone lead to reduction in 28 days mortality in patients with COVID pneumonia requiring oxygen. NICE recommends offering dexamethasone for 10 days in patients with COVID positive pneumonia. However, outcomes from real world data are lacking. Aim: The aim of this study was to analyse the impact of different duration of dexamethasone on mortality rate in patients with COVID positive pneumonia requiring oxygen. Method: The study was performed retrospectively from single centre using electronic PICS (prescribing information and communication system). We included patients admitted in hospital between the periods of 29/12/2020 to 7/1/2021 with diagnosis of COVID pneumonia, requiring dexamethasone. Data extracted included patient demographics, diabetes status and number of days on dexamethasone. We evaluated outcomes in three groups based on duration of dexamethasone as Group A (10 days), Group B (4-9 days) and Group C (≤3 days). Primary outcomes were mortality rate and length of stay. Results: We identified 179 patients. Mean (SD) age was 65 (17) years, 45.8% were female. Mean BMI was 31(14) kg/m2, 56.9% were Caucasian, 18.9% South Asian,4.4% were Afro-Caribbean,46.9% had diabetes. 128 patients were nursed on general medical ward (GIM) and 51 patients needed ITU setting. The mortality rate was 25 %, 20% and 43.7% in group A, B and C respectively. Mean length of stay (LOS) was 9 (11) days,10 (7) days and 9 (6) days in group A, B and C respectively. Further analysis of patients nursed on GIM ward showed mortality rate of 11.9%, 25% and 66.6% in group A, B and C suggesting an association between longer duration of dexamethasone and reduction in mortality. No difference in LOS was noted. No similar analysis was conducted in patients nursed on ITU setting because of small sample size. Discussion: Longer duration of dexamethasone was associated with better mortality rate in patients nursed on GIM ward and hence we should offer full course of 10 days dexamethasone in patients admitted with Covid pneumonia requiring oxygen. However, our study had small sample size, from single centre and result was not adjusted for co-variables like age, gender, BMI, and amount of oxygen requirement. We need future study with large sample size, multicentre and addressing these limitations.

A COHORT OF 79 CHILDREN WITH PAEDIATRIC MULTISYSTEM INFLAMMATORY SYNDROME ASSOCIATED WITH COVID-19

Background/Aims COVID-19 can manifest as a significant lung inflammation in adults. Although the course of disease is usually mild in children, it occasionally results in Paediatric Inflammatory Multisystem Syndrome temporally associated with COVID-19 (PIMS). We present a cohort of 79 children treated for PIMS-TS in Yorkshire, UK between May 2020 and September 2021. Methods This retrospective multicentre cohort study includes children fulfilling the case definition of PIMS-TS according to Royal College of Paediatrics and Child Health criteria. The collected data include demographics, clinical symptoms, laboratory results, echocardiographic findings, treatment and outcomes. Results Out of 79 PIMS-TS cases, 50 were male, 29 female. Ages were between 3 months and 16 years (median 7 years). 45 children were within the normal weight range for age, 4 underweight, 30 overweight. 41 children were Caucasian, 34 Asian, 2 African and 2 Afro-Caribbean origin. The median duration of admission was 7 days with range 0-21 days. All children had fever. In 51 cardiac involvement was detected (impaired cardiac function, pericardial effusion or changes on coronary arteries by echocardiographic examination). In 51 children a skin rash was observed (usually macular blanching confluent non-pruritic), 48 children had gastrointestinal symptoms such as abdominal pains, vomiting or diarrhoea, 39 children had non-purulent conjunctivitis, 13 children enlarged cervical lymph nodes. All patients initially received antibiotics and all but two were treated with an anti-platelet dose of aspirin, a small number early on with an anti-inflammatory dose of aspirin, 31 were treated with 3 consecutive infusions of intravenous methylprednisolone (IVMP) 10 mg/kg daily followed by a weaning dose of oral prednisolone, 35 by IVMP and intravenous immunoglobulins (IVIG), 9 by IVIG only. The duration of treatment by oral prednisolone was 3-35 days with median 15 days. Inotropic support for hypotension was needed in 18 cases and oxygen therapy in 11 cases. All children had a good outcome and are being followed-up in our Paediatric Rheumatology / Cardiology clinics at 1-2 weeks, 6 weeks, 6 months and 12 months. To date, follow-up at 12 months has shown resolution of cardiac abnormalities including initial mild dilatation of coronary arteries;most of our patients have fully recovered within 6 weeks. No patients had any thromboembolic event identified. After discharge from hospital self-limiting musculoskeletal pains, lethargy, peeling of palms and/or headaches were common. 3 patients received psychology support. Conclusion We report 100% survival in our cohort of patients with PIMS-TS. None of the patients represented with flare of the symptoms. The majority were treated by corticosteroids alone, or in combination with IVIG. We believe that advance knowledge of PIMS-TS (from colleagues in other regions in the UK, affected earlier), prompt treatment and structured follow-up approach by multi-disciplinary team contributed to the good outcomes so far.

The uptake of vaccinations in adults with sickle cell disease receiving care at the Cambridge University Hospitals NHS Foundation Trust

Those affected by sickle cell disease have an increased susceptibility to infection by encapsulated bacteria and hepatitis B virus due to reduced splenic function and increased likelihood of receiving blood transfusions. Sickle cell disease patients are also more likely to suffer from complications, such as vaso-occlusive crises or acute chest syndrome, following infection with influenza or COVID-19. Standards for Clinical Care of Adults with Sickle Cell Disease in the UK (2018) outline that that those with sickle cell disease are recommended to be vaccinated against invasive pneumococcal disease, Haemophilus influenza type B, Neisseria meningitis types ACWY and type B, hepatitis B, and influenza . These patients are also recommended to have their hepatitis B immunity reviewed annually and to receive a hepatitis B vaccination booster if hepatitis B surface antibody (HBsAb) levels are less than 100 mIU/ml. According to the Standards , hospital staff is advised to remind and check with the patients' primary care teams whether these vaccinations have been administered. In this audit, we examined the records of 64 patients with sickle cell disease who receive regular care at the Cambridge University Hospitals NHS Foundation Trust. We collected data on the uptake of the pneumococcal conjugate vaccine (PCV13), pneumococcal polysaccharide vaccine (PPV23 or Pneumovax) within 5 years, two doses of Meningitis B vaccine, Meningitis ACWY vaccine (MenACWY), Haemophilus influenzae type b vaccine (Hib/MenC), influenza vaccine within 1 year, hepatitis B vaccine (HepB), whether HBsAb levels have been reviewed within 1 year, HepB booster if HBsAb levels were less than 100 mIU/ml, and two doses of COVID-19 vaccine. These records were obtained from electrical medical records provided by patients' general practitioners. Data collection took place from 23 September to 4 November 2021. The uptake of vaccinations was 67.4% for PCV13, 61.0% for PPV23 or Pneumovax within 5 years, 75.0% for Hib/MenC, 45.3% for MenACWY, 42.2% for the first dose of MenB and 29.3% for the second dose of MenB, 54.7% for influenza within 1 year, 75.0% for HepB, 71.9% for the first dose of the COVID-19 vaccine, and 68.3% for the second dose of the COVID-19 vaccine. 43.8% had their HbsAB reviewed and 20.0% received a HepB booster following HBsAb levels of less than 100mIU/ml. The uptake levels for the recommended vaccinations are lower than expected in our hospital trust. The COVID-19 pandemic has highlighted the effect of health inequalities and the uptake of the vaccination programme by patients of different ethnicities. During our patient support group, patients identified the Tuskegee syphilis experiment as one of the reasons why there is still distrust of the medical profession by those with Afro-Caribbean heritage. Beyond directed patient education, more communication is needed with the primary care teams to raise awareness of which vaccinations are required for sickle cell patients. Certain vaccinations, such as MenACWY and MenB were only introduced in 2015, meaning that some general practitioners may be still unaware of their necessity in adults with sickle cell disease..

FACTORS ASSOCIATED WITH MORTALITY IN MULTI-ETHNIC HOSPITALISED COVID PATIENTS

Introduction: Whilst most patients during the COVID pandemic made an uneventful recovery, there was a significant minority in whom the disease was severe and unfortunately fatal. This survey aims to evaluate independent risk factors for those who died of COVID compared to survivors and to identify any markers for improvement in future management. Methods: Medical records of all COVID patients admitted to two multi-ethnic, inner city acute district general hospitals over a 6-week period in 2020 were examined. Data collected included demographic details, medical comorbidities, and type of ward where they received care. Multivariable analysis using stepwise backward logistic regression was conducted to examine independent risk factors for those who died from COVID compared to survivors. Results: Of 951 patients admitted with COVID, 284 died[30%]. Compared to survivors(n=667), univariate analyses revealed COVID deaths were associated with increasing age[mean(CI): 79.3(77.9-80.7)vs64.7(63.4-66.0);P<0.001], Black African [16.2%vs11.7%;p<0.001] & South-Asian [12%vs9.1%;p<0.001] ethnicity, Hypertension [64.4%vs49.5%;p<0.001],ChronicHeartDisease(CHD)[40.1%vs20.7%;p<0.001], Chronic Respiratory Disease [17.6%vs12.0%;p=0.02] Chronic Kidney Disease [18%vs11.1%;p=0.004], Chronic Neurological Disease 43.3%vs23.7%;p<0.001]. Gender, Diabetes, asthma, obesity, Chronic Liver Disease and immunosuppression (disease or treatment related) were not associated with increasing mortality. Death rates between those in general wards vs intensive care were comparable[4.7%vs2.5%;p=0.1]. Multivariable analyses showed age 60-70 [OR 2.3], age>70 [OR 6.5], Black Caribbean [OR 1.6], and CHD [1.5] were independent risk factors for COVID deaths. Discussion: This large multi-ethnic study showed that age>60, Black Caribbean, and chronic heart disease were independent risk factors for COVID deaths. This study provides valuable information on independent prognostic implications for COVID, which can be used in future interventional studies aiming to improve COVID outcomes or in audits of clinical practice.

Hyperglycaemic emergencies during the COVID-19 pandemic in East London, one of the worst affected areas in the UK

Introduction: Diabetes is an established risk factor for poor outcome in COVID-19. Additionally, the pandemic has resulted in patients delaying hospital attendance with emergencies such as diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS). We examined adult admissions for hyperglycaemic emergencies to Newham University Hospital during the first and second COVID-19 waves. Results: 38 adults presented in wave ( March to 3 May 2020): DKA, 4 HHS, 3 mixed DKA/HHS. Median age was 62 years and 58% were male. 63% were Afro-Caribbean,13% Caucasian,11% Asian. 68% had known T2DM, 6% known TDM and 6% newly diagnosed diabetes. Mean BMI was 27.3 kg/m2, mean HbA1c (within one year) was 90.6 mmol/mol. 6 patients (42%) had PCR-confirmed COVID-19 on admission. In wave 2 ( November 2020 to 28 February 202) 59 adults presented: 34 DKA, 2 HHS, 3 mixed DKA/HHS. Median age was 55 years and 6 % were male. 39% were Afro-Caribbean, 27% Caucasian, 7 % Asian. 6 % had known T2DM, 29% known TDM and 0% newly diagnosed diabetes. Mean BMI was 27.9 kg/m2, mean HbA1c was 96 mmol/mol. 8 patients (3%) had PCR-confirmed COVID-19 on admission. In both waves most patients were male, had T2DM with poor pre-admission glycaemic control and most were overweight/obese. Mixed DKA/HHS was unusually prevalent. During wave 2, patients were younger, COVID-19 was less frequent, more patients with TDM were admitted, when DKA predominated and only two patients with TDM had COVID-19. Hyperglycaemic emergency admissions differed between the two waves, with wave 2 seeing increased TDM admissions and more presentations independent of COVID-19 . Discussion: Better understanding of factors underlying these presentations could help to improve patient support during this time.

A case of Candida albicans septic sacroiliitis complicating severe COVID-19 infection

Case report-IntroductionBacterial and fungal infections are recognised complications of viral pneumonia, particularly in patients who are critically ill. We describe a case of fungal sacroiliitis complicating severe COVID-19 pneumonia following a prolonged intensive care unit (ICU) admission.Candida albicans sacroilitis is a rarely reported infection with few case reports in the literature. Candida osteoarticular infections can present as septic arthritis, with knee involvement in 75% of cases, or osteomyelitis. The latter presentation differs based on age-vertebral involvement (51%) is more common in adults while children are more likely to present with infection in the long bones, ribs, or sternum.Case report-Case descriptionA 48-year-old Afro-Caribbean gentleman with a history of hypertension and obesity was admitted to the ICU with clinical, laboratory and radiographic features of COVID-19 infection despite persistently negative swabs. Whilst in ICU he required mechanical ventilation. His stay was further complicated by multiple infections, pulmonary emboli, and the presence of a cavitating lesion in the left lung. Cultures from bronchoalveolar lavage and a central venous catheter line grew Serratia Mascense, candida glabrata and pseudomonas were isolated from his urine. He was treated with multiple antibiotics including meropenem, tazocin, ceftazidime and avibactam.After 61 days in the ICU he was transferred to the ward. He developed severe pain in his right hip which was worse on movement. This was followed by urinary incontinence and sensory deficit in the right L2/L3 dermatome. He underwent magnetic resonance imaging (MRI) of his spine and sacroiliac joints which showed right sided sacroiliitis and oedema around the iliopsoas muscle. He was started on vancomycin, later changed to ceftazidime avibactam and metronidazole. An echocardiogram did not show any vegetations. He underwent a biopsy of his sacroiliac joints which confirmed the presence of leucocytes, extended cultures yielded candida albicans in one out of two biopsy specimens.Considering ongoing pyrexia, pain and inflammatory markers, intravenous fluconazole was added to his antibiotic regimen which resulted in a marked improvement in mobility. After four weeks, ceftazidime, metronidazole and avibactam were stopped, and fluconazole was administered as oral tablets. 6 days later he became febrile and IV fluconazole was restarted.A repeat chest CT showed resolution of the cavity but ongoing changes suggestive of organising pneumonia. A repeat MRI of the sacroiliac joints revealed minor improvement. Intravenous Fluconazole was continued for a total of 8 weeks and was changed to tablets for complete a total of 12 weeks.Case report-DiscussionThis is a severe case of COVID-19 infection who despite 9 negative PCR tests, on day 53, had positive IgG for SARS-CoV-2 infection, confirming our clinical suspicion. Particularly in the ICU setting, individuals are approximately ten times more likely to have secondary bacterial/fungal infections with more frequent detection of multidrug-resistant Gram-negative pathogens.This case highlights several difficulties. Urine cultures had confirmed candida albicans, likely to be related to catheter related urinary tract infections, and a possible source for our patient but also a resistant pseudomonas aeruginosa species. Furthermore, cultures were positive for Serratia Mascense, candida glabrata. He had also already been treated with prolonged, broad spectrum antimicrobial treatment. Considering this, establishing the aetiology of the septic sacroiliitis was challenging. The rarity of candida sacroiliitis and presence of the organism in just one specimen made this more difficult. This led to the decision of a repeat sacroiliac biopsy to supply sufficient samples for further microbial analyses such as 16S, 18S and mycobacteria culture, all of which were negative.He became febrile after the discontinuation of antimicrobials and a switch to oral fluconazole therapy. He was extensively re-investigated and despite resolution of t e lung cavity, there were changes which could have been consistent with an organising pneumonia. At this point he was neutropenic, mildly eosinophilic, and therefore a drug reaction was also considered.Repeat MRI revealed resolving muscle inflammation and minimal change at the bone site, with erosions and possible reactive bone marrow oedema. Following discussion with microbiology the decision was made to persist with intravenous Fluconazole. He continued to improve, and his inflammatory markers normalised after 8 weeks of treatment. Prednisolone was started for COVID-19 related pneumonitis. Long-term antifungal treatment is advisable, and we aim to complete 12 weeks of treatment.Case report-Key learning points Patients with SARS-CoV-2 infection, particularly those requiring ICU admission were at risk of developing superinfections with multidrug-resistant Gram-negative bacteria or fungal infections.Candida albicans sacroiliitis is rare therefore early aspiration/biopsy is essential for the management.Longer treatment is needed in osteoarticular candida infections, even up to 6 or 12 months, therefor long-term close monitoring of this patients is essential.The utility and timing of reimaging patients following such infections is still unclearClose multidisciplinary and interdisciplinary team collaboration is essential in the management of this complex patients.

Unpacking the health and social consequences of COVID-19 through a race, migration and gender lens.

The ongoing COVID-19 pandemic has emerged as an unprecedented challenge for healthcare systems across the world. To date, there has been little application of a race, migration and gender lens to explore the long-term health and social consequences of COVID-19 in African, Caribbean and Black (ACB) communities in Canada, who have been disproportionately impacted by this pandemic. The evidence presented in this commentary suggests that recovery strategies need to adopt an intersectional lens taking into account race, migration and gender since ACB women and ACB immigrant women have been among the populations most impacted both personally and economically. To do so, there is an urgent need to incorporate variables capturing race, beyond "visible minority" status; gender, beyond looking at differences between women and men; and factors to help understand the complexities of migration trajectories (i.e., beyond the dichotomy of born in Canada versus not born in Canada categories) in Canadian datasets. We provide examples of policy and practice initiatives that will be urgently required to address the needs of these population groups as these race-based data become available.

RéSUMé: La pandémie de COVID-19 en cours se révèle être un défi sans précédent pour les systèmes de santé du monde entier. Jusqu'à maintenant, on a très peu appliqué le prisme de la race, de la migration et du genre pour explorer les conséquences sociosanitaires à long terme de la COVID-19 dans les communautés africaines, caribéennes et noires (ACN) du Canada, qui ont été démesurément touchées par cette pandémie. Selon les données probantes présentées dans notre commentaire, les stratégies de rétablissement doivent adopter un prisme intersectionnel qui tient compte de la race, de la migration et du genre, car les femmes ACN et les immigrantes ACN sont parmi les populations les plus touchées, personnellement et économiquement. Pour cela, il faut de toute urgence intégrer dans les jeux de données canadiens des variables qui saisissent la race, au-delà du statut de « minorité visible ¼; le genre, au-delà des différences entre femmes et hommes; et les facteurs qui aident à comprendre les trajectoires de migration dans toute leur complexité (c.-à-d. au-delà de la dichotomie des catégories « né au Canada ¼ et « né à l'étranger ¼). Nous donnons des exemples d'initiatives stratégiques et pratiques qui seront nécessaires à très court terme pour répondre aux besoins de ces segments démographiques à mesure que les données fondées sur la race deviendront disponibles.

Global Food Insecurity and African, Caribbean, and Black (ACB) Populations During the COVID-19 Pandemic: a Rapid Review.

BACKGROUND: The global food insecurity reinforces the ongoing impact of COVID-19 on human health and mortality. Although literature remained sparse, reports indicated that food insecurity is disproportionately high among African, Caribbean, and Black (ACB) population since the outset of COVID-19. Hence, we assessed the food insecurity conditions of ACB populations globally during the COVID-19 pandemic. METHODS: Comprehensive searches in CINAHL, Medline (Ovid), PubMed (Medline), Food Science and Technology Abstracts, SCOPUS, EMBASE, AMED, CAB Abstracts, Cochrane Library (OVID), and PsycINFO were carried out. Title/abstract and full-text screening, quality appraisal (modified JBI QARI), and data extraction were carried out by double reviewers. RESULTS: The initial search yielded 354 articles. After removal of duplicates and irrelevant articles, a full-text review and critical appraisal, 9 papers were included in the study. After data extraction and synthesis, six major themes emerged from the analysis: increased food insecurity, adverse health outcomes of food insecurity, exacerbation of existing disparities, systemic inequities and adverse policies, racism, and sociocultural response and solutions. CONCLUSION/IMPLICATIONS: The study showed that COVID-19 had exacerbated food insecurity and other health disparities within racialized populations including ACB people, due to systemic anti-Black racism; inadequate representation in decision-making; and issues of cultural appropriateness and competency of health services. While sociocultural response by ACB people through the expansion of their social capital is imperative, specific policies easing access to food, medicine, and shelter for racialized communities will ensure equity while reducing global food insecurity and health crises during the COVID-19 pandemic.