Diagnosing gestational diabetes during the Covid-19 pandemic using HbA1c rather than oral glucose tolerance test (OGTT)

The Royal College of Obstetrics and Gynaecology advocated replacing OGTT with HbA1c for gestational diabetes (GDM) screening for women with risk factors during the Covid-19 pandemic. HbA1c >=48mmol/mol/random plasma glucose (RPG) >=11.1mmol/l at booking indicated diabetes, and 41-47mmol/ mol/9-11mmol/ l prediabetes or possible GDM. Testing was repeated at 26 weeks if normal previously, with HbA1c >=39mmol/mol, fasting PG >=5.6mmol/l, or RPG >=9mmol/l diagnostic for GDM. A) At her clinic booking visit at 10 weeks gestation, 36 year-old South Asian female had HbA1c 55mmol/mol/RPG 9.5mmol/l suggesting undiagnosed type 2 diabetes. Initially managed with dietary advice and home blood glucose monitoring, metformin was added when self-monitored glucose above pregnancy targets (fasting and pre-meal <5.3mmol/l or 1 h post meal <7.8mmol/l) but insulin was required later. Metformin and insulin were stopped after delivery at 38 weeks with HbA1c 50mmol/mol three months postpartum, supporting the earlier diagnosis of type 2 diabetes. B) 32 year-old White Caucasian female was screened for GDM on booking at 11 weeks as BMI 38 kg/m2. HbA1c 44mmol/mol and RPG 6.9mmol/l confirmed GDM which was managed by dietary/lifestyle changes with glucose and pregnancy targets achieved until 28 weeks when metformin added. Normal delivery at 40 weeks with HbA1c 40mmol/mol three months postpartum triggered advice on long-term dietary/lifestyle changes and annual HbA1c checks. HbA1c was useful during the pandemic but most centres reverted to OGTT for GDM screening due to a significant fall in diagnoses using HbA1c >=39mmol/mol at 26 weeks. But, HbA1c testing was advantageous at booking to diagnose type 2 diabetes earlier.

Omicron driven ECMO in a vaccinated critically ill patient

Objectives: Reporting a case of a COVID-19 vaccinated patient admitted to our intensive care unit with severe acute respiratory failure due to SARSCoV2 - Omicron variant, rapidly deteriorating requiring intubation, prone ventilation, and ECMO support. Method(s): A 62 years old Caucasian male was admitted in ICU for rapidly deranging respiratory failure and fever which occurred over the previous 24h. The patient received two doses of SARS-CoV2 vaccine (Oxford, AstraZeneca), the last one over five months before onset of symptoms. The patient was admitted to the intensive care unit (ICU) with tachypnea, low peripheral saturation (80%), elevated serum creatinine (2.4 mg/dl), and mild obesity (BMI 34,6). Pressure support ventilation trial (2 hours) failed carryng out to orotracheal intubation and protective ventilation. Worsening of respiratory exchanges (5 th day from the admission) required a rescue prone ventilation cycle, in the meantime an indication was given to the placement of veno-venous ECMO. The cannulation site was femoro-femoral and the configuration used was Vivc25- Va21, according to the current ELSO nomenclature;ECMO flow was progressively increased until a peripheral saturation of 95% was obtained. Result(s): The patient passed out after 2 month of extracorporeal support with no sign of recovery of pulmonary and renal function. Conclusion(s): Unlike evidences showing a lower symptomatic engagement of the Omicron variant SARSCoV2 positive patients, we have witnessed a rapid and massive pulmonary involvement. The short time that passed from the onset of symptoms and the rapid decay of respiratory function required rapid escalation of the intensity of care up to extracorporeal support. The patient showed previous pathologies that can lead to suspicion of a loss of immune coverage given by the vaccine, in addition to the long time elapsed since the last dose. (Figure Presented).

COVID-19 Vaccination during Pregnancy: A Structured Electronic Medical Record Data Study

Objectives: To compare pregnancy loss rates, preterm birth rates and gestational age at delivery in women vaccinated against COVID-19 during pregnancy vs. those unvaccinated. Method(s): Data were captured from Dorsata Prenatal, an electronic medical record (EMR) system that captures obstetrical data for tens of thousands of pregnancies annually. Patients who delivered between February 11, 2021-June 2, 2022, were included. The vaccinated group included women who had at least one COVID-19 vaccination documented in their EMR between 30 days prior to pregnancy and delivery. The unvaccinated group included women without a COVID-19 vaccination documented. The primary outcome measure was gestational age (GA) at delivery. We analyzed the data using chi-square tests, with significance set at p<0.01. Result(s): A total of 51,994 pregnant women were identified-7,947 (15.3%) in the vaccinated group and 44,047 (84.7%) in the unvaccinated group. Vaccination rate varied by race (Asian: 19.7%;White: 17.3%;Black: 11.2%, P<0.001), ethnicity (Latino: 8.6%;Not-Latino: 18.7%;P<0.001), marital status (Married: 19.2%;Single: 8.8%;P<0.001), mother's age (>=35 years: 20.0%;<35 years 14.2%;P<0.001), and region (Northeast: 19.2%;South: 15.2%;West: 9.1%;P<0.001). The vaccinated group had significantly lower rate of preterm delivery (Gestational Age [GA]<37 weeks;vaccinated: 7.8% vs. unvaccinated: 9.6%;P<0.001), and significantly lower rates of pregnancy loss (GA<20 weeks;vaccinated: 1.1% vs. unvaccinated: 4.1%;P<0.001). Conclusion(s): This is one of the largest real-world studies to date in women who received the COVID-19 vaccination during pregnancy. Vaccination rates varied significantly across race/ethnicity. Vaccinated patients had lower preterm delivery and pregnancy loss rates compared with unvaccinated patients.Copyright © 2023

Uptake of the Post COVID-19 Condition ICD-10-CM Diagnosis Code By Social Factors

Objectives: Post-COVID conditions (PCC) are increasingly reported in people who had COVID. Certain racial or socioeconomic groups may be at greater risk for PCC and less likely to seek care. We examined the uptake of the new ICD-10-CM diagnosis code for PCC in routine clinical practice in the United States and how it varied by race and payer group. Method(s): Using the Optum de-identified Electronic Health Record (EHR) dataset, we identified patients with an ICD-10-CM code for PCC (U09.9) between October 1, 2021, through March 31, 2022, with 6 months of prior EHR activity. The earliest diagnosis defined the index date. All concurrent diagnoses were measured on the index date. Prior COVID diagnosis was assessed using all available data before the index date. Result(s): There were 23,647 patients: 9.9% were African American, 12.1% had Medicaid, and 2.4% were uninsured. There was an overrepresentation of white patients among those with PCC (78.6% compared with 69.6% of the overall EHR in 2021). More African American (24.1%), Medicaid (23.1%), and uninsured (27.5%) patients were diagnosed in the inpatient setting or emergency department than whites (14.0%) and commercially insured patients (10.0%). Among racial groups, African Americans had the highest percentage of documented prior COVID diagnosis at 63.6%. Of concurrent diagnoses, shortness of breath and acute respiratory failure with hypoxia were higher among African Americans (13.9% and 6.1%, respectively) than whites (11.5% and 4.3%, respectively). The same pattern was seen when comparing Medicaid and uninsured to commercial payors. Conclusion(s): The PCC code was used differently across racial groups and payor types and captures varying manifestations of PCC. The differences in diagnosis locations underscore the importance of using data capturing all care settings when conducting studies using this code. Subgroup analyses are important for future studies using U09.9 due to variability in code application.Copyright © 2023

The intersection of technology, ethnicity, deprivation, and the covid-19 pandemic: Lessons from the National Diabetes Audit

Introduction: The aim was to investigate access to and the effect of intermittency scanned flash glucose monitoring (isCGM) on glycaemic control during the Covid-19 pandemic. Method(s): Data from the National Diabetes Audit from 2019 to 2021 was stratified into those who were already using isCGM on 1st April 2020 (A), those who started isCGM on or after 1st April 2020 (B), and those who did not receive isCGM (C). Logistic regression investigated the independent effects of ethnicity and deprivation on access to isCGM after adjustment for baseline covariates (age, gender, BMI, duration of diabetes, and baseline HbA1c). Ethnicity was categorized as White, Asian, Black, Mixed, and not reported. The Index of Multiple Deprivation (IMD) was divided into quintiles. Result(s): 251,620 people were identified with type 1 diabetes;88,910 (35%) had isCGM prescribed at 1st April 2020. The mean follow-up post-isCGM initiation was six months. Mean HbA1c at baseline was 67.4mmol/mol in (A), 73.6mmol/mol in (B) and 69.7mmol/mol in (C). Mean HbA1c at follow-up was 64.9mmol/mol (A) (p < 0.001), 65.5mmol/mol (p < 0.001) (B). After adjustment for age, sex, duration of diagnosis, baseline HbA1c, and BMI people with White ethnicity (OR = 1.79 p < 0.001) or in the least deprived quintile (OR = 1.54, p < 0.001) were more likely to be initiated on isCGM as compared to the black and most deprived groups. Conclusion(s): Initiating isCGM during the Covid-19 pandemic was associated with improved glycaemic control. Ethnic and socioeconomic disparities in access to isCGM were observed even during the pandemic. Ongoing work is investigating the effect of isCGM on diabetes-related hospital admissions during the pandemic.

Telemedicine and the Utilization of Outpatient Mental Health Services By Patients with Incident Major Depressive Disorder during the COVID-19 Pandemic

Objectives: To examine the role of telemedicine in providing access to outpatient psychotherapy for children and young adults with incident major depressive disorder (MDD) before and during the COVID-19 pandemic, overall and by race and ethnicity. Method(s): Medical claims from a large, national insurer were retrospectively analyzed to identify two cohorts of individuals aged 10-26 years old, based on incident diagnosis ("index") date of MDD (pre-COVID: March-December 2018, COVID: March-December 2020). We tracked health care utilization, utilization by site of care, modality of care, and psychotherapy Results: The majority of patients in the two cohorts (pre-COVID: N=7,758, COVID: N=8,517) were White (78.9% and 78.8%, respectively), followed by Hispanic (11.5% and 10.9%), Black (6.6% and 7.1%), and Asian (3.0% and 3.2%). While pre-index utilization was similar between cohorts, the COVID cohort had 919 psychotherapy visits per 1,000 patients compared to 735 for the pre-COVID cohort in the month post-index. The increase in visits is largely attributable to an increase in telemedicine visits for the COVID cohort. Similarly, psychotherapy visits increased for all racial and ethnic groups in the COVID cohort compared to the pre-COVID cohort in the month post-index: 22.3% for Whites (931 visits per 1,000 patients in COVID cohort vs. 759 in pre-COVID cohort), 45.0% for Asians (951 vs. 656), 20.5% for Blacks (792 vs. 657) and 46.5% for Hispanics (860 vs. 587). Conclusion(s): Telemedicine increased access to mental health services during the pandemic across races and ethnicities, but racial and ethnic disparities persisted. Health systems should capitalize on the telehealth infrastructure developed during the pandemic to sustain this increased access to care while continuing work to reduce disparities.Copyright © 2023

COVID-19 vaccination rates in people living with HIV in north east England

Background: People living with HIV (PLWH) are at increased risk of severe COVID-19. The UK recommends vaccination against COVID-19 for PLWH with two primary doses, a booster dose, then seasonal boosters (i.e. four doses by Autumn 2022). Vaccination uptake in the UK has been lower among non-white minority ethnic groups than in the white British population, despite these groups having a higher risk of severe COVID-19. Method(s): We evaluated vaccine uptake by PLWH attending treatment services at two NHS Trusts in North East England. To ensure representation of minorities, alternating PLWH from white and ethnic minorities (excluding white minorities) were purposively selected for review from the HIV and AIDS Reporting System;vaccination data were obtained from regional integrated care records. Result(s): 200 PLWH were included. 103 (51.5%) were from ethnic minority groups, of whom 78 (75.7%) were of black African ethnicity. Vaccination rates in the total population and among ethnic groups are shown in the table below. Similar proportions of white and minority ethnic background PLWH had received up to two vaccinations. These proportions among white PLWH were similar to those reported in the general English population, while fewer Black African PLWH were unvaccinated than in the general population (14.1% vs. 26%, data not shown). Vaccine uptake among PLWH diverged beyond 3 doses, with white people being almost three times as likely to have received four doses (OR 2.92;95% CI 1.63 to 5.19;pvalue for difference in distribution across all doses=0.005). Conclusion(s): Although ethnic minority PLWH were less likely to be fully vaccinated than white ethnicity PLWH, the proportion of unvaccinated black African PLWH was lower than that reported from the general population. This could infer that regular contact with healthcare professionals coupled with consistent promotion of vaccination by HIV clinicians can improve uptake. (Table Presented).

One-Year Long-Term Follow up for Post-Acute Sequelae of Covid-19 Pots Patients

Background: Persistence of orthostatic tachycardia, palpitations, and fatigue beyond 4 weeks of an acute COVID-19 infection has been termed Post-Acute Sequelae of COVID-19 (PASC) POTS. We have previously reported 6-month outcomes of PASC POTS. Long-term management and outcomes of these patients is unknown. Objective(s): To examine the long-term management and outcomes of PASC POTS patients. Method(s): We conducted a retrospective study of all patients who were diagnosed with POTS at Cardiology, Neurology, and Rehabilitation Post-COVID clinic after a COVID-19 infection between March 1, 2020, and November 1, 2022, at the University of Texas Health San Antonio. We examined COVID history, POTS diagnosis, management, and one-year outcomes of post-COVID POTS patients. Result(s): In 42 patients that were diagnosed with PASC POTS, 33 had a one-year follow-up. 100% were female, 60.6% were Caucasian. Average age was 40.6 + 11 years while the average BMI was 31.9 + 10.4 kg/m2. The most common symptoms were fatigue (87.9%), palpitations (75.7%), brain fog (72.7%), orthostatic tachycardia, exercise intolerance, and dyspnea (70%). The mean heart rate change with 10-minute standing test was 42.68 + 26.73 beats per minute. At 12-months follow-up, the most common symptom was still fatigue (66.7%), palpitations (45.5%), orthostatic tachycardia, and orthostatic intolerance (42.4%). All patients were managed with increased salt and fluid intake, lower compression stockings and rehabilitation. Fifty five percent of patients were treated with Enhanced External Counter Pulsation (EECP), 42% were treated with beta blockers, 18% with fludrocortisone, 15% with midodrine, and 15% with Pyridostigmine. At 1 year follow-up, 33% of patients reported improvement in their symptoms, 33% reported worsening of symptoms, 24% reported stable symptoms, and 9% had resolution. Conclusion(s): PASC POTS patients continue to experience adverse symptoms even at one year. Physical therapy and rehabilitation and pharmacological therapy appear improve symptoms in a minority of patients.Copyright © 2023

Flares Following Covid-19 Vaccination in Patients with Idiopathic Inflammatory Myopathies: Combined Analysis from the Covid-19 Vaccination in Autoimmune Diseases (Covad) Studies

Background/Aims Flares following COVID-19 vaccination are an emerging concern among patients with rare rheumatic disease like idiopathic inflammatory myositis (IIMs), whereas data and understanding of this is rather limited. We aimed to study the prevalence, characteristics and determinants of IIM flares following COVID-19 vaccination. Methods CoVAD (COVID-19 Vaccination In Autoimmune Diseases) surveys are global patient self-reported e-surveys from 109 countries conducted in 2021 and 2022. Flares of IIM were defined by 4 definitions;a. patient self-reported, b. physician and immunosuppression (IS) denoted, c. sign directed (new erythematous rash, or worsening myositis or arthritis), d. MCID worsening of PROMISPF10a score between the patients who had taken both surveys. Descriptive statistics and multivariate regression were used to describe the predictors of flare. Cox-regression analysis was used to differentiate flares by IIM subtypes. Results Among the 1,278 IIM patients, aged 63 (50-71) years, 276 (21.5%) were dermatomyositis, 237 (18.5%) IBM, 899 (70.3%) were female and most were Caucasian (80.8%). Flares of IIM were seen in 123/1278 (9.6%), 163/1278 (12.7%), 112/1278 (8.7%), and 16/96 (19.6%) by definitions a-d respectively with median time to flare being 71.5 (10.7- 235) days. Muscle weakness (69.1%), and fatigue (56.9%) were the most common symptoms of flare. The predictors of self-reported flare were: inactive/disease in remission prior to first dose of vaccine (OR=4.3, 95%CI=2.4-7.6), and anxiety disorder (OR=2.2, 95%CI=1.1-4.7). Rituximab use (OR=0.3, 95%CI=0.1-0.7) and IBM (OR=0.3, 95%CI=0.1-0.7) were protective. Physician defined flares were seen more often in females, mixed ethnicity, and those with asthma, ILD, and anxiety disorder (OR ranging 1.6-7.0, all p<0.05). Notably, overlap myositis (OM) had higher HR for flare compared to polymyositis (HR=2.3, 95%CI=1.2-4.4, p=0.010). Conclusion Nearly one in ten individuals with IIM develop flares after vaccination, more so among women, those with overlap myositis, and inactive disease prior to vaccination. Formal definition of flares in IIM is needed.

Patient Experience of Remote Healthcare during the Pandemic in Rheumatoid Arthritis and Adult Juvenile Idiopathic Arthritis

Background/Aims COVID-19 challenged traditional care models and necessitated introduction of remote consultations. We wanted to understand the experiences of people with rheumatoid arthritis (RA)/adult juvenile idiopathic arthritis (AJIA) on accessing healthcare remotely, and how well people understood their condition and treatment. Methods This collaborative work between the National Rheumatoid Arthritis Society (NRAS) and clinicians in Oxford led to the development of an electronic questionnaire that was disseminated in July 2021 for four weeks through e-newsletters and all NRAS social media platforms. Those living in the UK with RA and AJIA aged 18 and over were eligible. Analyses of data were performed in Microsoft Excel and IBM SPSSv28. Results We analysed 316 responses. There was a middle-aged (ages 46 to 54, 54.1%, n=171), Caucasian (97.5%, n=306), female (92.4%, n=292) preponderance. Most had RA (93%, n=294) followed by another inflammatory arthritis (4.1%, n=13) and AJIA (2.8%, n=9). The majority had their condition for >10 years (43.4%, n=137) but some were diagnosed <12 months ago (3.2%, n=10). Two thirds of participants (66.5%, n=210) did not know their DAS28 score. Of the remaining third, the most commonly reported measure was moderate disease activity (12%, n=38). Those with higher self-reported DAS28 scores were using analgesia more regularly (p<0.01) but we found no difference in NSAID, DMARD or steroid use. Age did not influence steroid usage (p=0.35), but those who had their condition for longer used more steroids and regular analgesia. Only 33.9% (n=107) of responders felt their condition had been managed adequately in the pandemic, with more reporting poor status (40.8%, n=129) rather than good (16.8%, n=53). Those living in the South of England reported statistically better disease control than those from the North, despite having more virtual assessments (p=0.02). Travelling and fear of Covid appeared more important than consultation skills. Just over a fifth (20.3%, n=64) felt greater focus should be given to patient concerns. Of the 9.1% of patients (n=29) with a new diagnosis made during the pandemic, 24.1% (n=7) unable to book a GP appointment easily. Patients experienced a median symptom time of 4-10 weeks before consulting GPs. Once assessed, 31% (n=9) were referred immediately while the median time was 4-8 weeks. We found 58.6% (n=17) of patients received their diagnosis within their initial rheumatology consultation and 76.5% (n=13) of these started a DMARD immediately. Conclusion Despite a greater emphasis on patient education and PROMs influencing clinical decision-making, it is staggering that two-thirds did not know their DAS28 score. Analgesia and steroid use were common in patients with well-established disease which remains a concern. Accessing appointments was a significant barrier to patients and delays in care were experienced at every step in the NHS management pathways. Remote consultations need greater emphasis on patient concerns.

Risk Factors for Supraventricular Tachycardia among Covid-19 Positive Octogenarians and Potential Outcomes

Background: COVID-19 tends to have a harsher course in the elderly population, which can include the development of arrhythmias, including supraventricular tachycardia (SVT). Due to lack of sufficient data, we studied baseline patient characteristics, comorbidities, and outcomes of SVT in octogenarians admitted with COVID-19, using the 2020 National Inpatient Sample (NIS). Objective(s): We aimed to study the patient characteristics and outcomes of SVT in octogenarians admitted with COVID-19, using the 2020 National Inpatient Sample (NIS). Method(s): Octogenarians (ages 80-89 years, inclusive) with COVID-19 were recruited from the 2020 NIS (April 1st 2020 - December 31st 2020). A diagnosis of SVT was identified via the ICD-10 code "I47. 1". Patient characteristics that can influence the presence of SVT were identified via logistic regression models. The adjusted odds ratios (aOR) having cardiogenic shock or mortality among COVID-19 positive octogenarians with SVT were also explored. Result(s): Our study consisted of 240570 octogenarians who tested positive for COVID-19. 2.2% of them (5250 cases) also had a diagnosis of SVT during their hospitalization. Among them, Females (aOR 0.919, 95%CI 0.868-0.973, p<0.01) were more likely to develop SVT. Racial disparities were also observed as Blacks (aOR 1.234, 95%CI 1.137-1.338, p<0.01) had higher odds of having SVT, whereas Hispanics (aOR 0.898, 95%CI 0.819-0.984, p=0.021) had lower odds compared to Whites. Comorbidities such as chronic pulmonary disease (aOR 1.106, 95%CI 1.037-1.179, p<0.01), and heart failure (aOR 1.122, 95%CI 1.053-1.195, p<0.01) also led to higher odds of SVT. Lower odds were seen among those with diabetes (aOR 0.852, 95%CI 0.802-0.905, p<0.01), obesity (aOR 0.839, 95%CI 0.764-0.921, p<0.01), or smoking history (aOR 0.892, 95%CI 0.835-0.954, p<0.01). The use of mechanical ventilation (aOR 2.829, 95%CI 2.638-3.034, p<0.01) or non-invasive ventilation (aOR 1.755, 95%CI 1.615-1.907, p<0.01) showed higher odds of developing SVT. Finally, patients with SVT had increased risk of cardiogenic shock (aOR 1.510, 95%CI 1.206-1.891, p<0.01) and mortality (aOR 1.166, 95%CI 1.085-1.253, p<0.01). Conclusion(s): Multiple factors influenced the presence of SVT among octogenarians who had COVID-19. SVT in these patients was associated with higher incidences of cardiogenic shock and mortality. Additional focus targeting patient care and further research to better understand the mechanisms behind these variations may help improve outcomes. [Formula presented]Copyright © 2023

Synchronous and Asynchronous Atrial Fibrillation Education Directed by Allied Professionals for Improved Patient Care

Background: Patient education programs are an integral component of care, which helps promote patient engagement and improved clinical outcomes. The role and durability of virtual learning programs for patients (pts) with atrial fibrillation (AF) requires further study. Objective(s): To assess the utilization, acceptance, durability, and benefits of virtual learning for pts with atrial fibrillation as well as the impact on virtual care models. Method(s): A comprehensive 3-hour virtual symposium on AF via an online video platform was offered to pts and family in 2021 and 2022. The program was sponsored by an academic teaching hospital free to pts and promoted through social media. Participants could watch live and the recorded presentation was also made available for future viewing. A follow up survey was sent to attendees that included questions on demographic information and opinions regarding virtual education and care. Comparisons were made between the 2022 and 2021 programs. Result(s): A total of 465 participants registered for the 2022 program (48% increase from 2021) and 146 participants logged on (31% of registrants - down from 34% in 2021). A follow-up survey was sent to all registrants with 55 respondents, (89% watched the program live). Most respondents were >65 years old (58%);female (76%), Caucasian (89%), completed graduate school (40%) and lived 50+ miles away (36%). Four patients were from outside the US. Minority populations were under-represented relative to the local population demographics (black 0%, Hispanic 1.8%). The total cost of the program was $20/pt. The majority of respondents (58% - an increase of 22% from 2021) indicated they preferred a virtual program and if they had a choice, 61% preferred virtual (11% increase);and 53% indicated that program participation increased the likelihood of them performing a remote/virtual clinic visit with their provider. COVID was no longer an influence for most (57.4%). Presentations were made publicly available after the October 2022 program and have been viewed 247 times. Conclusion(s): Virtual education for pts with AF can be successfully offered, with a high enrollment rate at a fraction of the cost of an in-person program. Attendees generally prefer virtual over in person and can increase participation worldwide. This program influences future acceptance of virtual care as well as potential models of virtual care delivery. Greater efforts need to be made, however, to include under-represented populations. [Formula presented]Copyright © 2023

A Rare Cause of Enteritis in an Adult Male

Introduction: IgA vasculitis is more commonly seen in the pediatric population than in adults. Rarely IgA vasculitis is associated with malignancy, most commonly solid tumor malignancies, although there are case reports of association with hematologic malignancies. We report a case of large B-cell lymphoma mimicking IgA vasculitis in a 33-year-old immunosuppressed male with a prior history of IgA vasculitis. Case Description/Methods: A 33-year-old Caucasian male post renal transplant from reflux nephropathy on chronic immunosuppression was hospitalized for postprandial epigastric abdominal pain, nausea, vomiting and diarrhea. Two years prior, he was admitted for the same symptoms, palpable purpura of the lower extremities and elevated serum IgA. Enteroscopy had shown duodenal and jejunal ulceration with biopsies staining positive for IgA, confirming IgA vasculitis. He had complete resolution with a steroid taper. His current presentation had resulted in multiple hospital admissions, but empiric trial of steroids failed to alleviate symptoms. Vitals were normal and exam was notable for epigastric tenderness. Labs were notable for WBC 19.00 x103/cmm with normal differential, hemoglobin 9.2 gm/dL (prior 11.0 gm/dL), CRP 20.7 mg/L, serum creatinine 2.7 mg/dL (prior 1.5 mg/dL), and urinalysis with proteinuria, sterile pyuria, and hematuria. CTA abdomen/pelvis revealed thickening of the duodenum with shotty mesenteric lymph nodes without ischemia. Enteroscopy revealed an erythematous duodenum and jejunum (figure A). Jejunal biopsy (figure B) revealed CD20 positive cells consistent with DLCBL (figure C). He was seen by oncology and treated with R-CHOP but later unfortunately expired due to COVID-19 complications. Discussion(s): Non small cell lung cancer and renal cell carcinoma are most commonly associated with IgA vasculitis. It may also be seen in both Hodgkin and Non-Hodgkin lymphomas in adult patients. If IgA vasculitis occurs after a malignancy is diagnosed, it may indicate that metastasis has occurred. Malignancy associated IgA vasculitis is more likely to have an incomplete response to steroids and requires treatment of the underlying malignancy to achieve remission. Our case illustrates posterior probability error and premature closure cognitive biases. We should consider alternative diagnoses rather than anchor on prior diagnoses even when presentations are similar. Our case also highlights the importance of considering occult malignancy in adults with diagnosis of IgA vasculitis.

Impact of Covid-19 Pandemic on Pharmacologic Treatment of Patients Newly Diagnosed with Osteoporosis

Purpose of Study: The COVID-19 pandemic has presented considerable challenges in the care of patients with chronic diseases, including osteoporosis. In this study, we determined whether initiation of pharmacologic treatment was delayed for patients who were newly diagnosed with osteoporosis during the pandemic. Methods Used: Patients >= 50 years who were newly diagnosed with osteoporosis using dual-energy x-ray absorptiometry (DXA) screening at a single academic institution were included. Patients with osteoporosis diagnosed between March 1, 2018 to January 31, 2020 (pre-pandemic cohort) were compared to patients diagnosed between March 1, 2020 to January 31, 2022 (pandemic cohort). Basic demographics including age, gender, race, and ethnicity were evaluated. Primary outcomes included the proportion of patients who were initiated on pharmacologic therapy at 3-months and 6-months of diagnosis, as well as the mean time from osteoporosis diagnosis to initiation of pharmacologic treatment. Ordering providers (primary care vs specialty care providers) and types of pharmacologic agents were also compared. Summary of Results: In total, 1,189 were newly diagnosed with osteoporosis on DXA during the study period, with 576 patients in the pre-pandemic cohort and 613 in the pandemic cohort. There was no significant difference between cohorts with regard to age (69.3 vs 68.8 years, p=0.33), gender (87.0 vs 86.1% female, p=0.67), or ethnicity (88.2 vs 86.0% Non-Hispanic, p=0.25). However, there was a higher proportion of Whites in the pre-pandemic cohort (74.1 vs 68.4%, p=.028). Overall, only 40.5% of patients (n=481) newly diagnosed with osteoporosis were started on pharmacologic therapy within 6 months of diagnosis. Proportions of patients treated at 3-months (31.8 vs 35.4%, p=0.19) and at 6-months (37.8 vs 42.9, p=0.08) were comparable between cohorts (47.2 vs 50.2% p=0.30). Mean time from osteoporosis diagnosis to initiation of pharmacologic treatment was similar (46 vs 45 days, p=0.72). Ordering providers did not differ between cohorts (65.1 vs 57.4% primary care providers, p=0.08). Bisphosphonates were the most often prescribed in pre-pandemic (90%) and pandemic cohorts (82.1%). Conclusion(s): This is the first study to compare the impact of the COVID-19 pandemic on the pharmacologic treatment of patients who were newly diagnosed with osteoporosis. In our retrospective comparative study, we found only 40.5% of patients with newly diagnosed osteoporosis were treated pharmacologically within 6 months of diagnosis, and the COVID-19 pandemic did not significantly affect treatment rates. Bisphosphonates were the most often prescribed medication group. Further studies are needed to better understand patient-, provider-, and system-specific factors contributing to the low treatment rates of patients newly diagnosed with osteoporosis.

Hospitalisation and death in lung transplant recipients following COVID-19 infection

Introduction/Aim: Rates of hospitalisation and death from COVID-19 in lung transplant (LTx) recipients vary internationally. We aimed to assess risk factors for this in an Australian cohort. Method(s): We performed a retrospective cohort study of all LTx recipients between January 2020 and September 2022. LTx recipients with COVID-19 were included. Baseline characteristics and treatments were recorded. Multivariate logistic regression was performed to identify risk factors associated with hospitalisation and death. Result(s): 128/387 (33%) recipients tested positive to SARS-CoV-2 during the study period, 97.6% during the Omicron waves with 40(31.3%) requiring hospitalisation and 10 (7.8%) died. The median (IQR) recipient age was 50.6 (22-77). The cohort was of Caucasian ethnicity 105 (82%), 48% were female with high vaccination rates (98.4%). Chronic lung allograft dysfunction (CLAD) was present in 48 (37.5%). 103 (80.5%) of patients received early SARS-CoV-2 treatment with either Sotrovimab 84(65%), Molnupirivir 50(39%) or combination 31(24%). 25 patients (19.5%) received no early treatment. All hospitalised patients received Remdesivir and Dexamethasone as per local treatment protocols. Regarding risk of hospitalisation, multivariate analysis showed that recipient age (1-unit change OR 1.04 95% CI 1.01-1.07 p = 0.019) was associated with an increased risk, whereas Molnupiravir was protective (OR 0.32 95% CI 0.13-0.80 p = 0.02). In univariable analysis, increasing age (1-unit change, OR 1.07 95% CI 1.02-1.129 p = 0.01) and severe disease (OR 9.95 95% CI 2.58-38.32 p =< 0.001) were associated with an increased risk of death. Male gender, non-Caucasian ethnicity, CLAD, CKD stage 3-5 were correlated with death with weak association. Conclusion(s): Recipient age is a significant risk factor for both hospitalisation and death, and older patients with COVID-19 should be monitored closely during COVID-19 illness. Molnupirivir is protective against hospitalisation, with Sotrovimab having a weak association. Further analysis of the protective effect of pre-exposure prophylaxis with emerging therapies such as Evusheld would be helpful to fully evaluate the currently available early disease therapies in Australia.

COVID pneumonitis, a risk factor for persistent lung allograft dysfunction

Introduction/Aim: There is a paucity of data regarding the impact of COVID-19 on allograft function in lung transplant (LTx) recipients. Method(s): We performed a retrospective cohort study of all living LTx recipients in our service between January 2020 and September 2022. Patients with COVID-19 were identified and baseline characteristics recorded. Pre- and post-COVID-19 spirometry was used to identify persistent decline in allograft function (>=10% of FEV 1 decline at 90 days after infection and failure to return to baseline during the study period). Multivariable logistic regression was performed to identify risk factors associated with persistent allograft decline. Result(s): 128/387 (33%) LTx recipients tested positive to SARS-CoV-2 during the study period. The majority, 125 (97%) during the Omicron waves. In those with COVID-19, the median (IQR) recipient age was 50.6 (22-77) with median time post-transplant of 1522 (17-9842) days. The cohort was of Caucasian ethnicity, 105 (82%), with vaccination rates (98.4%) and 48% female. Chronic lung allograft dysfunction (CLAD) was present at time of infection in 48 (37.5%). Severe disease (oxygen requirement) was present in 40 (31%) patients and 10 (7.8%) died. Recipients were followed for median of 172 days (range 90-339) post infection. Persistent FEV 1 decline occurred in 37 (31.4%). Multivariate analysis showed severe disease was independently associated with an increased risk of persistent FEV 1 decline (OR 5.55 [95% CI 2.28-13.48] p =< 0.001). Non-Caucasian ethnicity (OR 2.83, [95% CI 0.92-8.65], p = 0.07) and the presence of CLAD (OR 2.39, [95% CI 0.94-6.08], p = 0.06), were positively correlated, with weak association. No significant association between recipient age, gender, time post-transplant, early COVID therapy, SARS-CoV-2 variant with persistent FEV 1 decline was seen. Conclusion(s): Persistent decline in lung allograft function is common post COVID-19 infection. Severe disease is strongly associated with this outcome and these patients should be monitored for poor long-term allograft recovery. Further investigation into pathological mechanisms responsible for persistent allograft decline is required.

Attitudes amidst the pandemic: Virtual delivery of care in an adult cystic fibrosis population

Background: The COVID-19 pandemic has altered how we deliver care to people with cystic fibrosis (CF) across the spectrum of disease severity. Because of lockdowns and avoiding exposure to COVID-19 by limiting inperson clinic visits, clinical care has pivoted from standard practices to virtual care in combination with in-person traditional visits. This approach has allowed patients to be monitored and treated in a timely manner. Such virtual visits have the advantage of reducing the time commitment for clinic visits because the patient does not have to travel to and from the hospital, but virtual care lacks the ability to conduct a physical examination and to obtain objective and standardized testing of key measurements known to be associated with health outcomes in CF. The objective of this study was to evaluate the attitude of patients to virtual delivery of care and their comfort level with such care. Method(s): This is a prospective, cross-sectional survey of adults with CF who are followed at St. Michael's Adult CF Center in Toronto, Canada. An online survey was created using SurveyMonkey to assess attitudes toward and satisfaction with virtual care. The survey was emailed to participants and included the Canadian CF Registry ID;a reminder email sent a week later. Baseline demographic and clinical data were obtained from the Canadian CF Registry and presented as median (range) or proportions as appropriate. Questions using a 3-point Likert scale will be categorized into agree, neutral, and disagree. Result(s): A total of 210 participants (53.0% female) completed the survey (median age 37.8, range 19.2-78.9). Median age of diagnosis was 2.2, 95.7% were Caucasian, 76.0% had completed post-secondary education, 63.0% were employed and 11.0% were students, 75% were pancreatic insufficient, 39.0% had CF-related diabetes, and 12.4% were post lung-transplant. Median percentage predicted forced expiratory volume in 1 second was 65.8% (range 17.9-126.9%), and median body mass index was 23.6 kg/m2 (range 15.5-45.7 kg/m2). Eighty-one percent of respondents had had a virtual visit before completing the survey. Sixty percent of respondents felt that in-person visits were the preferred way of completing a medical assessment, and 27.0% preferred virtual visits. Seventy-three percent felt it was important for the virtual visit to occur at the booked time, 59.0% had concerns that their lung function was not assessed during virtual visits, 46.0% felt they were losing the benefits of allied health team assessments with virtual visits, and 40.0% worried that their health would decline if primarily seen virtually. Just over half of respondents wanted to continue with virtual visits in some capacity after the pandemic. The optimal proportion of in-person visits was felt to be 50.0%. More than 85% of respondents were comfortable with technology (phone or computer) and had reliable access to the Internet to conduct virtual visits. Seventy percent of people would like to have access to a home spirometer, but cost was a barrier. Conclusion(s): From the patient's perspective, in-person visits were still the preferred way to complete a medical assessment, which seemed to be driven by concerns over lack of methods for assessment, particularly lung function, and access to the multidisciplinary team. Home spirometers, if freely available, might increase comfort with virtual appointments.Copyright © 2022, European Cystic Fibrosis Society. All rights reserved

PREVALENCE AND CORRELATES OF SARS-CoV-2 VACCINE HESITANCY AMONG US PEOPLE WITH HIV

Background: People with HIV (PWH) have a higher risk of COVID-19 morbidity and mortality. SARS-CoV-2 vaccination is highly effective in preventing severe COVID-19, although medical mistrust may contribute to vaccine hesitancy among PWH. Method(s): PWH from 8 sites in the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) completed the clinical assessment of patient-reported outcomes including a vaccine hesitancy instrument as part of routine care from 2/21-4/22. Participants were defined as vaccine hesitant if they had not yet received the SARS-CoV-2 vaccine and would probably or definitely not receive it. We assessed factors associated with SARS-CoV-2 vaccine hesitancy using logistic regression, and adjusted for demographics, unsuppressed viral load >200 copies/mL, calendar month and time on ART. Result(s): Overall, 3,278 PWH with a median age of 55 responded;19% were female sex at birth;93% were virally suppressed. At the time of survey, 27% reported they had not received the SARS-CoV-2 vaccine, of whom 27% (n=242;7% overall) reported vaccine hesitancy. Of these 242, 82% expressed concerns about vaccine efficacy;86% about side effects;38% reported distrust of healthcare, 53% reported concerns about vaccine contents (i.e. trackers, live virus);and 24% did not perceive risk from COVID-19. Factors associated with vaccine hesitancy included female sex (Adjusted Odds Ratio [AOR] 2.0;95% Confidence Interval (CI): 1.5-2.8;Table), Black vs. White race (AOR 1.8;95% CI: 1.3-2.5), age< 30 years (AOR 2.8;95% CI: 1.5-5.2), South/Midwest vs. Northeast region (AOR 1.7;95% CI: 1.2-2.4), years on ART (0.8;0.7-0.9) and unsuppressed viral load (AOR 2.2;95% CI: 1.4-3.5). Hesitancy decreased over time (AOR 0.9 per month;95% CI: 0.8-0.9). Vaccine side effects were the primary concern for women;vaccine contents for Black PWH and those who were unsuppressed;and lack of perceived COVID-19 risk for youth. Conclusion(s): Vaccine hesitancy was reported by approximately 7% of a U.S. multi-site cohort of PWH, and it was more prevalent among Black PWH, women, youth, those with unsuppressed viral loads, and residents of the South/ Midwest. The association between virologic non-suppression and vaccine hesitancy highlights the intertwined challenge of medical mistrust for both HIV and COVID-19. Although vaccine hesitancy decreased over time, renewed efforts will be needed to address concerns of PWH about the COVID-19 vaccine, given the ongoing need for revaccination with the evolution of the pandemic.

COVID-19 as a probable cause of acute pancreatic injury

Acute pancreatic pseudocysts are increasingly recognized as complications in patients with coronavirus disease 2019 (COVID-19). There-fore, it is important for healthcare providers to be aware of this phenomenon to ensure proper diagnosis and treatment. Up to 17% of patients with severe acute respiratory syndrome corona-virus 2 (SARS-CoV-2) infection have been shown to develop pancreatic lesions. These pancreatic lesions can be caused directly by the cytopathic effects of the viral infection or indirectly by systemic responses to inflammation or respiratory failure. Several studies have shown that angio-tensin-converting enzyme 2 (ACE2) is the functional receptor used by SARS-CoV-2 to gain access to target cells, while ACE2 receptors are expressed in significant amounts in the pancreas. In this article, we present 2 cases of COVID-19. patients that presented with similar pancreatic lesions. The first case was a 47-year-old lady who presented to the emergency department (ED) with flu-like symptoms for ten days. Incidental findings on computed tomography (CT) scan showed a large, multiloculated cystic mass in the pancreatic tail. The second case was an 81-year-old Caucasian lady who presented to the outpatient clinic with multiple chronic complaints after an acute COVID-19 infection four months prior. Abdominal CT scan with oral contrast revealed multiple hypodense masses on the pancreas measuring 0.3 cm in diameter. The cases we reported in this article showed the degree of COVID-19's effect on the gastrointestinal system, with pancreatic injury occurring during the early phases of the acute phase of the infection and lasting up to 4 months post-resolution of the infection.Copyright © 2023, The Indonesian Foundation of Critical Care Medicine. All rights reserved.

Early infection risk in patients with systemic lupus erythematosus treated with rituximab or belimumab from the British Isles Lupus Assessment Group Biologics Register (BILAG-BR): a prospective longitudinal study

Background: Patients with systemic lupus erythematosus (SLE) are at an increased risk of infection relative to the general population. We aimed to describe the frequency and risk factors for serious infections in patients with moderate-to-severe SLE treated with rituximab, belimumab, and standard of care therapies in a large national observational cohort. Method(s): The British Isles Lupus Assessment Group Biologics Register (BILAG-BR) is a UK-based prospective register of patients with SLE. Patients were recruited by their treating physician as part of their scheduled care from 64 centres across the UK by use of a standardised case report form. Inclusion criteria for the BILAG-BR included age older than 5 years, ability to provide informed consent, a diagnosis of SLE, and starting a new biological therapy within the last 12 months or a new standard of care drug within the last month. The primary outcome for this study was the rate of serious infections within the first 12 months of therapy. Serious infections were defined as those requiring intravenous antibiotic treatment, hospital admission, or resulting in morbidity or death. Infection and mortality data were collected from study centres and further mortality data were collected from the UK Office for National Statistics. The relationship between serious infection and drug type was analysed using a multiple-failure Cox proportional hazards model. Finding(s): Between July 1, 2010, and Feb 23, 2021, 1383 individuals were recruited to the BILAG-BR. 335 patients were excluded from this analysis. The remaining 1048 participants contributed 1002.7 person-years of follow-up and included 746 (71%) participants on rituximab, 119 (11%) participants on belimumab, and 183 (17%) participants on standard of care. The median age of the cohort was 39 years (IQR 30-50), 942 (90%) of 1048 patients were women and 106 (10%) were men. Of the patients with available ethnicity data, 514 (56%) of 911 were White, 169 (19%) were Asian, 161 (18%) were Black, and 67 (7%) were of multiple-mixed or other ethnic backgrounds. 118 serious infections occurred in 76 individuals during the 12-month study period, which included 92 serious infections in 58 individuals on rituximab, eight serious infections in five individuals receiving belimumab, and 18 serious infections in 13 individuals on standard of care. The overall crude incidence rate of serious infection was 117.7 (95% CI 98.3-141.0) per 1000 person-years. Compared with standard of care, the serious infection risk was similar in the rituximab (adjusted hazard ratio [HR] 1.68 [0.60-4.68]) and belimumab groups (1.01 [0.21-4.80]). Across the whole cohort in multivariate analysis, serious infection risk was associated with prednisolone dose (>10 mg;2.38 [95%CI 1.47-3.84]), hypogammaglobulinaemia (<6 g/L;2.16 [1.38-3.37]), and multimorbidity (1.45 [1.17-1.80]). Additional concomitant immunosuppressive use appeared to be associated with a reduced risk (0.60 [0.41-0.90]). We found no significant safety signals regarding atypical infections. Six infection-related deaths occurred at a median of 121 days (IQR 60-151) days from cohort entry. Interpretation(s): In patients with moderate-to-severe SLE, rituximab, belimumab, and standard immunosuppressive therapy have similar serious infection risks. Key risk factors for serious infections included multimorbidity, hypogammaglobulinaemia, and increased glucocorticoid doses. When considering the risk of serious infection, we propose that immunosupppressives, rituximab, and belimumab should be prioritised as mainstay therapies to optimise SLE management and support proactive minimisation of glucocorticoid use. Funding(s): None.Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license