PSYCHOLOGICAL DISTRESS OVER 12 MONTHS POST-DIAGNOSIS IN A NATIONAL EARLY INFLAMMATORY ARTHRITIS COHORT

BackgroundIn inflammatory arthritis patients, the concomitant decline of their mental wellbeing is an increasing concern[1,2]. It is important to not only describe the trajectory of psychological distress in early disease stages, but also understand which clinical outcome measures are most associated with these changes.ObjectivesUsing data from the National Early Inflammatory Arthritis Audit (NEIAA), we assessed trends in psychological wellbeing over 12 months after initial diagnosis and mapped these against clinical outcomes to identify significant associations.MethodsNEIAA collects data from patients referred with suspected early inflammatory arthritis in rheumatology services in England and Wales. We used data provided by 20,472 patients eligible for follow-up (diagnosis of inflammatory arthritis) between May 1st, 2018, and April 1st, 2022. Data items included baseline demographics e.g., age and gender, and clinical variables e.g., rheumatic disease comorbidity index (RDCI), DAS28, and patient reported outcomes.Psychological distress was measured by the sum score of Patient Health Questionnaire Anxiety and Depression Screener (PHQ4ADS). Using mixed effects regression models, we analysed the co-variability of PHQ4ADS with demographic factors and clinical outcomes over 12 months. Time was included as a dummy-coded covariant.ResultsThe analysis included 36% of patients (7,378 out of 20,472) who completed the baseline patient outcome survey. In this cohort, PHQ4ADS scores decreased from a baseline average of 4.7 (CI: [4.6, 4.8]) to 2.62 (CI: [2.5, 2.8]) at 12 months post-diagnosis. The proportion of patients screening positive decreased from 50.0% (CI: [48.9, 51.1]) at baseline to 23.8% (CI: [21.8, 25.9]) at 12 months.At baseline, psychological distress correlated significantly with age, gender, ethnicity, RDCI, prior depression diagnosis, and baseline DAS28 (Figure 1). No significant correlations were found between psychological distress and working diagnosis, seropositivity, or the assessment being recorded after the start of the COVID-19 pandemic. Younger ages were nonlinearly associated with higher distress levels (coefficient per decade: -0.006;p<0.001;CI: [-0.009, -0.003]) (Figure 1a). Distress levels in females were higher than that of males (coefficient: 0.5;p<0.001;CI: [0.4, 0.7]) (Figure 1b). White patients reported lower PHQ4ADS scores compared to non-white patients (coefficient: -0.7;p<0.001;CI: [-1.0, -0.4]) (Figure 1c). Higher distress levels were also associated with higher RDCI (coefficient: 0.2;p<0.001;CI: [0.1, 0.3]) and prior diagnosis of depression (coefficient: 1.8;p<0.001;CI: [1.5, 2.2]) (Figure 1d, 1e). Furthermore, higher baseline DAS28 scores correlated with more severe psychological distress (coefficient: 0.8;p<0.001;CI: [0.7, 0.8]) (Figure 1f).By 12-months, psychological distress decreased significantly overall, which correlated significantly with ethnicity (coefficient: 0.8;p=0.005;CI: [0.3, 1.4]) and baseline DAS28 (coefficient: -0.5;p<0.001;CI: [-0.6, -0.4]). Compared to white patients, the reduction was significantly greater for non-white patients, but the level of distress was no longer different at 12 months (Figure 1c). While those with higher baseline DAS28 showed a greater reduction in psychological distress, the distress levels remained higher at 12 months (Figure 1f).Figure 1.Changes in psychological distress correlated with age, gender, ethnicity, RDCI, prior depression diagnosis, and baseline DAS28.[Figure omitted. See PDF]ConclusionIn this early inflammatory arthritis cohort, mental health burden was high. Age, gender, ethnicity, RDCI, prior depression diagnosis and baseline DAS28 significantly correlated with psychological distress at baseline. Supporting mental health should be a focus of clinical care for this population and it may be beneficial to use an approach that is culturally valid for non-white patients and accounts for multimorbidity.References[1]Euesden, J, et al. Psychosomatic medicine 79.6 (2017): 638.[2]Lwin, MN, et al. Rheumatology and therapy 7.3 (2020): 457-471.AcknowledgementsThe authors would like to thank the Healthcare Quality Improvement Partnership (HQIP) as the commisioner of NEIAA, British Society for Rheumatology as the audit providers, Net Solving as the audit platform developers, and the Wellcome Trust (ST12406) for funding to support L.Z..Disclosure of InterestsLucy Zhao: None declared, James Galloway Speakers bureau: Has received honoraria from AbbVie Celgene, Chugai, Gillead, Janssen, Eli Lilly, Pfizer, Roche, and UCB, Jo Ledingham: None declared, Sarah Gallagher: None declared, Neena Garnavos: None declared, Paul Amlani-Hatcher: None declared, Nicky Wilson: None declared, Lewis Carpenter Consultant of: Statistical consultancy for Pfizer, Kirsty Bannister: None declared, Sam Norton Speakers bureau: Has received honoraria from Janssen and Pfizer.

Depression Severity Among Patients with Psychiatric Disorders during the COVID-19 Pandemic

Objectives: The impact of the COVID-19 pandemic on mental health is not yet well-studied. This study's objective is to describe demographic characteristics of the population diagnosed with depression or anxiety, and to compare PHQ9 scores before and after the pandemic. Method(s): A retrospective cohort study was performed using Komodo Health's healthcare claims and EMR data, which included Patient Health Questionnaire-9 (PHQ9) survey responses. The study's baseline and follow-up periods were set as one year before and after 03/01/2020. Patients selected were >=18 years of age, had a MDD, GAD, or other psychiatric diagnosis in both periods, and had taken at least one PHQ9 survey in both periods, resulting in 10,433 patients. Demographic characteristics were described across age, gender, and race/ethnicity, and a subgroup analysis was performed on PHQ9 scores and depression categories using averages (mean, SD) and odds ratios. Result(s): Demographic analysis showed depression severity correlated with patients who were younger, female, and Black or Hispanic. Younger patients (<30) were more likely than older (>=30) to be in the moderately severe category or worse (PHQ9 score >=15) in both time periods (ORs 1.72 and 1.62, p<0.001). This was also true for female as compared to male (ORs 1.45 and 1.49, p<0.001), and Black or Hispanic as compared to White (ORs 1.87 and 1.47, p<0.001). However, mean PHQ9 scores tended to decrease in the follow-up period. The overall mean decreased slightly from 6.28 (SD 6.05) to 5.68 (SD 5.82), which was consistent in nearly all age, gender, and race/ethnicity subcategories. Conclusion(s): While the improvements in average PHQ9 scores were counterintuitive, given the harmful impacts of the pandemic, existing correlations between demographics and depression severity remained. One possible explanation is that this cohort definition selected for patients who received more consistent mental healthcare. Further study will investigate this and other possible factors.Copyright © 2023

Evaluating real world clinical response of once weekly subcutaneous semaglutide and its daily oral formulation for the treatment of type 2 diabetes in primary care practice

Objective: Semaglutide is the first glucagon-like peptide- 1 receptor agonist with oral and subcutaneous formulations. We studied patient adherence and clinical response following their prescription in a primary care setting. Method(s): We searched for patients starting semaglutide between October 2020 to November 2021 in primary care registries in Dudley, West Midlands. We tracked their collection of medications for up to six months, changes in HbA1C and weight if these data were available at 26 weeks (range 22-52 weeks), with significance tested using a t-test. Patients prescribed both formulations were excluded. Result(s): Clinical data were available in 180 of the 443 patients. Baseline HbA1c was 79.0 +/- 18.6mmol/mol (Ozempic) and 81.9 +/- 19.3mmol/mol (Rybelsus) and pre-treatment weight was 108.4 +/- 10.5 kg (Ozempic) and 104.3 +/- 26.7 kg (Rybelsus). 62.8% of patients were of non-white ethnicity and 82.8% were on >= two anti-diabetic drugs. In patients with six-month follow-up data, mean reduction in HbA1c and weight was 17.1 +/- 20.8mmol/ mol and 3.9 +/- 6.2 kg (Ozempic n = 53, p < 0.01) and 18.2 +/- 14.5mmol/mol and 5.9 +/- 4.2 kg (Rybelsus n = 5, p < 0.05). Drug continuation rates were measured in 324 patients. 3.2% and 19.0% of patients for Ozempic and Rybelsus respectively did not obtain further prescriptions after their initial script. At six months, 87.2% continued with Ozempic and 57.2% with Rybelsus. Conclusion(s): This study demonstrates similarly significant reductions in HbA1c and weight with Ozempic and Rybelsus, despite the complexity of follow-up during Covid-19 restrictions. The lower adherence to Rybelsus warrants further study.

Innovative Methods for Integrating Social Determinants of Health Data with Administrative Claims to Facilitate Health Equity Research

Objectives: The Covid-19 pandemic highlighted the importance of considering Social Determinants of Health (SDoH) in healthcare research. Administrative claims databases are widely used for research, but often lack SDoH data or sufficient transparency in how these data were obtained. This study describes innovative methods for integrating SDoH data with administrative claims to facilitate health equity research. Method(s): The HealthCore Integrated Research Database (HIRD) contains medical and pharmacy claims from a large, national US payer starting in 2006 and includes commercial (Comm), Medicare Advantage (MCare), and Medicaid (MCaid) populations. The HIRD includes individually identifiable information, which was used for linking with SDoH data from the following sources: national neighborhood-level data from the American Community Survey, the Food Access Research Atlas, and the National Center for Health Statistics' urbanicity classification;and member-level data on race/ethnicity from enrollment files, medical records, self-attestation, and imputation algorithms. We examined SDoH metrics for members enrolled as of 05-July-2022 and compared them to the respective US national data using descriptive statistics. We also examined telehealth utilization in 2022. Result(s): SDoH data were available for ~95% of currently active members in the HIRD (Comm/MCare/MCaid 12.5m/1m/7.6m). Socioeconomic characteristics at the neighborhood-level differed by membership type and vs. national data: % of members with at least a high-school education (90/88/84 vs. 87);median family income ($98k/$76k/$70k vs. $82k);% of members living in low-income low-food-access tracts (9/14/18 vs. 13);urban (57/52/47 vs. 61). At the member-level, the % of White Non-Hispanics, Black Non-Hispanics, Asian Non-Hispanics, and Hispanics were 61/6/5/6 (Comm), 76/12/2/2 (MCare), and 45/26/5/19 (MCaid). Imputation contributed 15-60% of race/ethnicity values across membership types. Telehealth utilization increased with socioeconomic status. Conclusion(s): We successfully integrated SDoH data from a variety of sources with administrative claims. SDoH characteristics differed by type of insurance coverage and were associated with differences in telehealth utilization.Copyright © 2023

Ethnic, racial and migrant inequalities in respiratory health

Disparities in the incidence, prevalence, and morbidity and mortality rates of many respiratory diseases are evident among ethnic groups. Biological, cultural and environmental factors related to ethnicity can all contribute to the differences in respiratory health observed among ethnic minority groups, but the inequalities observed are most commonly due to lower socioeconomic position. People who migrate within a country or across an international border may experience an improvement in respiratory health associated with improvements in socioeconomic position. However, migrants may also experience worse health outcomes in destination countries, as they are faced by barriers in language and culture, discrimination, exclusion and limited access to health services. While some high-quality studies investigating ethnicity and respiratory health are available, further research into ethnic differences is needed. Improving the recording of ethnicity in health records, addressing barriers to accessing respiratory healthcare and improving cultural literacy more generally are some of the ways that inequalities can be tackled.Copyright © ERS 2023.

Managing diabetes remotely: Evaluation of the uptake and efficacy of the DBm app

Objectives: Insulin optimisation requires review of glucose monitoring;Covid-19 posed challenges to this. We evaluated DBm -a remote monitoring platform utilising a glucometer and smartphone app. Method(s): Evaluation was from January to November 2021. Inclusion criteria was insulin treated diabetes with HbA1c greater than 68mmol/mol. HbA1c, demographics, frequency of CBG uploads and interactions with clinicians were collected. Result(s): 97 patients were offered DBm. 48.5% used the app. There were no statistically significant differences in gender (p = 0.05), age (p = 0.36), type of diabetes (p = 0.13) or deprivation index (p = 0.96) between users and non-users. Patients of white ethnicity were less likely to use the platform (p = 0.01). Amongst users, 70% had a reduction of HbA1c of at least 5mmol/mol over six months, with a mean reduction of 25.6mmol/mol (p = 0.01). There was no difference in age (p = 0.64), gender (p = 0.4), and type of diabetes (p = 0.23) between responders and non-responders. There was also no difference in number of call back requests generated by patients (p = 0.32) or number of CBG uploads (p = 0.899) between responders and non-responders. Conclusion(s): Uptake of the remote monitoring solution was just under 50%, with no evidence of digital exclusion, although the finding that white ethnicity patients were less likely to use the system needs further exploration. Most users had improved glucose control, but there was no association with numbers of tests or call back requests. This study demonstrates that insulin optimisation can effectively be delivered using a remote glucose monitoring system. Future work will explore patient experience and patient satisfaction.

Impact of the COVID-19 Pandemic on Cervical Cancer Screening Rates in Colombia: An Interrupted Time Series Analysis, Stratified By Region

Objectives: The objective of this study is to measure the national impact of COVID-19 on cervical cancer screening rates in Colombia in five of its geographic regions to inform future health policy decision making. Method(s): This study utilized a quasi-experimental interrupted time-series design to examine changes in trends for the number of cervical cancer screenings performed in five geographic regions of Colombia. Result(s): In the rural region of Vichada, we found the lowest incidence of cervical cancer screenings, totaling at 3,771 screenings. In Cundinamarca, the region which hosts the capital city, a total of 1,213,048 cervical cancer screenings were performed. The researcher measured the impact on cervical cancer screenings in December 2021 against the counterfactual. This impact was ~269 cases that were not performed in December 2021 as a result of the COVID-19 pandemic compared to the counterfactual. In Cundinamarca, unlike other regions, we observed a stagnant pre-pandemic trend, a sharp drop in screenings in March 2020, and an immediate upward trend starting in April 2020. In the month of April 2020, compared to the counterfactual, there were 27,359 screenings missed, and by the month of December 2021, there were only 5,633 cervical cancer screenings missed. Conclusion(s): The region of Cundinamarca's sharp climb back to pre-pandemic screening levels could signal the relatively stronger communication system in the region, and especially in the capital district of Bogota, in re-activating the economy. This can serve as an example of what should be implemented in other regions to improve cervical cancer screening rates. Areas for further research include the examination of social determinants of health, such as the breakdown of the type of insurance screened patients hold (public versus private), zone (urban versus rural), insurance providers of those screened, ethnicities of the patients screened, and percentage of screenings that resulted in early detection of cervical cancer.Copyright © 2023

Bridging the gap: the challenge of mitigating health inequalities in lung cancer

Background: The COVID-19 pandemic, together with the cost-of- living crisis, have shone a light on health inequalities running through our society - not least in UK lung cancer. Lung cancer has the widest deprivation gap of all cancers. Despite published data about socio-economic factors, the amount of evidence available about other health inequalities is poor. Method(s): The Bridging the Gap report is the output from a Health Inequalities focus-group meeting of the UKLCC's Clinical Advisory Group in June 2022. These opinions were supplemented by views and information gathered from 15 interviews with leading lung cancer and health inequalities experts, from across the four UK nations in August/September 2022. Further desk research and literature reviews were carried out over the same period. Result(s): The report calls for a 'comprehensive' approach to data collection on health inequalities - to bridge gaps in current knowledge, improve outcomes and ensure people with lung cancer have equitable access to diagnosis, treatment, and care - wherever they live and from whatever background. Key recommendations include: * Extending the remit of the National Lung Cancer Audit (NLCA) to collect more data on ethnicity, LGBTQ+ and other health inequality factors - such as gender, religion and disability. * Establishing a single, coordinated data strategy, compiling evidence on health inequalities at local, regional and national levels. * Introducing a Personal Care and Access Card scheme, carried by the patient, combining their Holistic Needs Assessment information with their personal treatment and care plan to facilitate transfer of information between hospitals and specialists. * Disease awareness campaigns targeted to address local needs and communities. Conclusion(s): The UKLCC believes that - with the implementation of these recommendations and support from policy makers, commissioners and clinicians - we can successfully mitigate health inequalities in lung cancer and have further impact on lung cancer outcomes. Report accessible here: www.uklcc.org.uk/our-reports Disclosure: No significant relationships.Copyright © 2023 Elsevier B.V.

Post-Pandemic Onset Trends for Public School English Learners in Virginia. COVID-19 Impacts Research Brief Series No. 3

The COVID-19 pandemic impacted the educational experiences of diverse student populations throughout the country and among Virginia public schools. English Learners (ELs) had a unique set of needs and services prior to the pandemic, and potentially were more vulnerable to pandemic-related disruptions in typical school operations than other student groups. We analyze statewide, student-level administrative data on the composition of the EL population, the identification for and reclassification out of EL services, and the exit of ELs from public school enrollment in kindergarten through grade twelve between the 2010-11 and 2020-21 school years to examine changes between the pre-pandemic period and first post-pandemic onset year (2020-21). Our key findings include the following: (1) Following the onset of the pandemic, the number of students classified as EL decreased for the first time in a decade. Specifically, whereas the number of students classified as EL increased by 26.0% (25,171 more students) between 2010-11 and 2019-20, the number of students classified as EL decreased by 3.2% (3,852 fewer students) between 2019-20 and the first post-pandemic onset year (2020-21). (2) There was a 21.6% decline (6,223 fewer students) in the number of Virginia K-12 public school students newly identified for EL services in 2020-21 as compared to 2019-20. The drop in new EL identification occurred across student groups, but was largest among Hispanic students, economically disadvantaged students, and ninth graders. (3) The number of EL students reclassified as fully English proficient decreased by 57.3% (8,169 fewer students) in 2020-21 as compared to the pre-pandemic period. This decline is nearly three times the size of the previous largest year-to-year change. The drops in reclassification among ELs occurred across student groups and were somewhat larger among Hispanic and economically disadvantaged students. (4) EL students' exits from Virginia public schools in the post-pandemic onset were a continuation of pre-pandemic trends and did not meaningfully vary by race/ethnicity, economically disadvantaged status, or disability status.

Vaccination status of the adult sickle cell anaemia population: The South Wales experience

The Sickle Cell Society have issued standards for additional immunisations that adults with sickle cell disease (SCD) require. These include annual influenza, 5-yearly pneumococcal conjugate vaccine (PPV23) and Hepatitis B vaccination. Patients who have not received their primary vaccination as part of the national schedule in the UK should also receive further additional vaccines. We reviewed whether adults with SCD in South Wales currently receive these. 49 adult patients were identified as having SCD under the care of the Hereditary Anaemia Service based in the University Hospital of Wales, Cardiff. GP records were not available for 5 patients leaving a final cohort of 44 patients to analyse. Average age was 33 years (range 17-67). Median age was 27 with the cohort predominantly lying in the 17-29 year category (52%). Results showed good compliance with the annual influenza vaccine in those over 40 (>80%). However, compliance for the 17-29 category and 30-39 categories were 37.5% and 42.8%, respectively. The improved compliance in those >40 was not seen with the 5-yearly pneumococcal vaccine. Compliance was worse in all age groups compared to the annual flu vaccine with only 23% compliance overall. However, when looking at those who had received a single dose of PPV23, the numbers improved to nearly 60%. Compliance with the SARS-CoV2 vaccination was highest at 61.3%. However, rates were lower in the 17-29 and 30-39 age groups in keeping with previous trends. Only 34.1% of patients had full hepatitis B cover. Again, trends in compliance mirrored previous with poorer rates in those under 40. Assessing compliance for the remainder of the standards was more challenging given that we could not confirm retrospectively how many of our cohort had received their primary vaccinations in other parts of the UK, thought to be around half. However, most of the cohort had not received any additional vaccines suggesting high non-compliance regardless. This review looked at data from 2020 and likely reflects the impact of the SARS-CoV2, whether positive or negative. The reduced compliance in 5-yearly pneumococcal compared to flu suggest better health-professional education is needed;if patients are attending for their annual flu vaccine, there is ample opportunity to administer other vaccines. The vaccination rate for our patient group is comparable to national rates by ethnicity although lower than the national average for age. Vaccination rates for the SCD population of South Wales are not adequate. Better education and engagement is needed.

Multisystem Inflammatory Syndrome in Children: Characteristics and Epidemiology

Shortly after the novel coronavirus (now known as SARSCoV- 2) was recognized, data began to accumulate on the virus's effects on children. Initial data showed that children were more likely to be mildly affected, compared to adults, with lower risks of hospitalization and death. However, in April of 2020, reports appeared of a severe disease in children occurring about two-six weeks after infection with SARS-CoV-2. The features were similar to those seen in a rare vasculitis condition called Kawasaki disease. On May 14, 2020, the Centers for Disease Control and Prevention (CDC) issued a national health advisory regarding this new condition, which was called multisystem inflammatory syndrome in children (MIS-C). The current case definition for MIS-C includes six criteria: (1) serious illness leading to hospitalization or resulting in death;(2) age less than 21 years;(3) measured fever over 38 degrees Celsius or report of subjective fever;(4) laboratory evidence of inflammation;(5) new onset involvement in at least two of the following (cardiac involvement, mucocutaneous involvement, shock, gastrointestinal involvement, and hematologic involvement);and (6) laboratory-confirmed SARS-CoV-2 infection or an epidemiologic link to a person with COVID-19. According to CDC, as of January 3, 2023, there have been 9,333 patients in the United States meeting the case definition of MIS-C, with 76 deaths. The median age of patients was nine years, with half of those affected between the ages of five and 13 years. More than half of the reported patients on whom race-ethnicity information was available were in children who are Hispanic/Latino or Black, non-Hispanic. Over 60% of reported patients were male. Most affected children had previously been healthy. A better understanding of the pathogenesis of this serious illness is needed to provide better treatment options for children with MIS-C. Prevention of MIS-C is focused on the prevention of SARS-CoV-2 infection through staying up to date with COVID-19 vaccination, masking, and other prevention strategies.

How to read a paper about inequality in respiratory disease: Basic epidemiological principles and how inequalities are measured

Health inequalities in respiratory disease are widespread, and monitoring them is important for advocacy, the design and delivery of health services, and informing wider health policy. In this chapter, we introduce the different ways in which health inequalities can be quantified, including measures that quantify absolute and relative inequalities, and those that measure gaps between groups or differences across the entire social gradient. We consider the strengths and limitations of these different approaches and highlight things to look out for when reading a paper on health inequalities in respiratory health. These include how common the outcome is and whether other factors have been adjusted for, as both can have a crucial impact on interpretation and can lead to misleading conclusions.Copyright © ERS 2023.

Association of Long COVID with Seeing Difficulties Among Adults in the United States

Objectives: Many patients with long COVID experience at least one vision problem. This study determines the association of long COVID with seeing difficulties. Method(s): We conducted a cross-sectional analysis with the Census Household Pulse Survey data (N = 51,288). We excluded adults who reported contracting COVID within the past four weeks, those with missing data on seeing difficulty when infected with COVID, and long COVID. Long COVID was defined as having symptoms lasting three months or longer that the adults did not have prior to having COVID. Adults self-reporting to a question on seeing with "some difficulty," "a lot of difficulty," or "unable to do" were classified as having "seeing difficulties." We conducted Chi-square tests and logistic regressions with replicate weights. Logistic regressions adjusted for long COVID, sex, age, race and ethnicity, marital status, income, education, food sufficiency, health insurance, remote work, vaccine doses, region, depression, and anxiety. Result(s): During the survey period (November 2 - November 14, 2022), 37.3% reported seeing difficulties, and 14.4% reported long COVID. A higher percentage of adults with long COVID reported seeing difficulties than those without long COVID (47.6% vs. 31.9%). In the fully adjusted logistic regression model, compared to adults with no COVID or without long COVID, those with long COVID had greater odds of seeing difficulties (AOR = 1.50, 95%CI = 1.32, 1.70). We did not observe a statistically significant difference between adults without long COVID and no COVID (AOR = 1.01, 95%CI = 0.93, 1.10 p = 0.7888). Conclusion(s): One in eight adults had long COVID. Adults with long COVID had significantly higher odds of seeing difficulties than those without long COVID. Therefore, a follow-up of patients with long COVID needs to include screening for seeing difficulties. More research is needed on the links between long Covid and vision care.Copyright © 2023

Diversity in medical publications: a cross-sectional evaluation of COVID- 19 vaccine research

Objective: Representing diverse perspectives in medical publications is of great importance. We assessed diversity among investigators, study participants, authors and tweeters of recent publications on COVID-19 vaccine trials, a topic likely to have significant global implications. Research design and methods: Primary publications reporting on COVID vaccine randomized controlled trials (RCTs) were identified via PubMed (n=302 hits, 23 September 2022). The 100 articles with the greatest impact (Altmetric score) were selected for evaluation. National affiliation of authors and investigators, and demographics of participants were collected. Geographic locations of Tweets mentioning the publications were collected via Altmetric. Result(s): In our preliminary analysis, as expected, selected publications most frequently appeared in top-tier journals, e.g. New England Journal of Medicine (n=24) and Lancet (n=19), and had high Altmetric scores (median 886, range 30-29,153). Articles included authors from mean 2.2 countries, most frequently the USA (n=43 articles), the UK (n=31) and China (n=23). Investigators' locations were often not reported, but most frequent were the UK (n=2711 investigators), USA (n=1029) and South Africa (n=269). There was a gender balance among participants across the studies (mean 49.4% female). The most frequent ethnic groups were white, Hispanic and Asian. Tweets mentioning the publications most commonly came from the USA (8.1%), the UK (3.1%) and Japan (2.9%). Conclusion(s): Despite COVID-19 being a global health emergency, most authors, investigators and readers of high impact COVID-19 vaccine RCT publications were from a small group of countries, with some notable exceptions. Numerous studies did not report the geographic location of investigators or participant ethnicity. Consistent and transparent reporting would support the drive towards greater diversity and representation in medical research.

COVID-19 Vaccine Hesitancy and Health Literacy in US Southern States

The following are the highlights of our study: * Vaccine hesitancy in Southern states is complex and extends beyond health literacy. * Vaccine hesitancy in Southern states transcends many sociodemographic differences. * Effective public health communication should be unambiguous about negative externalities of COVID-19 beyond individual threats. _____ The COVID-19 pandemic caused by SARS-CoV-2 remains a public health crisis, accounting for more than 100 million confirmed cases with more than 1,121,800 deaths in the United States as of April 26, 2023.1 Despite widespread vaccination efforts by the US government and public health leadership, the rate of vaccine uptake is still far from desirable, as researchers estimate that about 70% to 85% of the country will need to be immunized before SARS-CoV-2 can be fully contained through herd immunity.2 As of April 19, 2023, about 81% of the US population had received at least 1 dose, whereas 69.4% had completed a full primary vaccine series and only 16.7% had received an updated bivalent booster, with variations in the rate of vaccination across states and regions.3 The Southern states (Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, South Carolina, Tennessee, Texas, Virginia, and West Virginia) have relatively lower rates of full vaccination (primary series) compared with other states (mean of 61.3%, ranging from 53.2% in Alabama to 79.9% in Maryland);6 Southern states rank among the 10 states with the lowest fully vaccinated rates in the nation.3 The predominant barrier to uptake has been vaccine hesitancy,4-9 defined as the intention to delay or refuse taking vaccinations despite availability and accessibility.10,11 It may be influenced by complex contextual factors, ranging from individual and group factors to vaccine-specific characteristics.10 In particular, individual factors may be related to health literacy (HL),12 which is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.13 HL is a phenomenon that involves individuals, families, communities, and systems, and it could be implicated in the level of COVID-19 vaccine hesitancy.5 Although HL is a major determinant of individuals' health behaviors,14 a systematic review study reported that HL's relationship with vaccination uptake prior to the COVID-19 pandemic was unclear because of variations in assessment tools, target populations, and outcome measures across available limited studies.15 Evidence suggests a relationship between HL and COVID-19 vaccine hesitancy.12,16,17 In the United States, a study among women recently released from jails found that low HL is related to COVID-19 vaccine hesitancy.16 Similarly, a study in Turkey found that low HL and a high perception of health care system distrust are associated with higher vaccine hesitancy.17 A study in China found that higher HL is associated with low likelihood of COVID-19 vaccine hesitancy, and the effect was moderated by stress.12 Overall, to the best of our knowledge, no study has examined the association between HL and COVID-19 vaccine hesitancy in populations with low vaccine uptake within the United States, including those residing in the Southern states, which served as the impetus for this study.18,19 This study aimed to estimate the level of HL among a population residing in Southern states and its association with vaccine hesitancy. Nearly 20% of the United States population had still not received a single dose of COVID-19 vaccine as of April 26, 2023, despite increases in both vaccine availability and individual eligibility over the previous 2 years.20 The observed trends in overall and region-specific COVID-19 cases and rates of vaccination in the United States demonstrate the need to examine the impact of HL on vaccine hesitancy in the Southern states, especially with the release of simplified eligibility guidelines and expanded booster recommendations.21 METHODS Participants This study included adults 18 years and older. Upon receiving institutional review board (IRB) approval from East Tennessee State University (IRB No. c0221.22e), a cross-sectional study was initiated. Race/ethnicity was collected as: (1) Asian or Pacific Islander, (2) Black or African American, (3) Hispanic/Latino, (4) Native American or Alaskan Native, (5) non-Hispanic White, (6) biracial or multicultural, and (7) race/ethnicity not listed here. Because of small sample sizes for non-White racial/ethnic groups in the study population, race/ethnicity was recoded as non-Hispanic White and other.

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

Association of state-level COVID-19 mortality rates with real-world progression and real-world overall survival among patients with advanced non-small cell lung cancer, 2020-2022

Background: The COVID-19 pandemic impacted the delivery of cancer care and outcomes in the United States (US). We examined the association between time-varying state-level weekly COVID19 mortality and progression-free survival (rwPFS), time to progression (rwTTP), and survival (rwOS) among pts with advanced non-small cell lung cancer (advNSCLC). Method(s): This retrospective study used the nationwide Flatiron Health electronic health recordderived de-identified database. The cohort included community oncology pts diagnosed with advNSCLC between March 1, 2020 and December 31, 2021 (follow-up through March 30, 2022). We extracted US data on COVID-19 deaths from the COVID-19 Data Repository by the Center for Systems Science and Engineering at Johns Hopkins University. We calculated state-level weekly COVID-19 death rates as weekly COVID-19 deaths per state population size from the 2019 American Community Survey. We categorized rates into quintiles based on all weekly rates during the observation period. Analyses were restricted to treated pts and indexed to start of first-line therapy. For rwPFS analyses, first occurrence of progression or death was considered an event, and pts were censored at last clinic note date. For rwTTP, only progression (not death) was considered an event, and pts with no event were censored at last clinic note date. For rwOS analyses, pts who did not die were censored at last structured activity. We used Cox proportional hazards models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for associations between weekly time-varying state-level COVID-19 mortality rates and outcomes of rwPFS, rwTTP, and rwOS, adjusted for age at diagnosis, race/ethnicity, and state. Result(s): Among 7,813 advNSCLC pts, the median age at diagnosis was 70 years, the majority of the cohort was non-Hispanic White (59%), had non-squamous cell histology (68%) and a history of smoking (87%). Compared to pts living in states with the lowest quintile of COVID-19 mortality rates (Q1), pts living in states with the highest COVID-19 mortality (Q5) had worse rwOS (Q5 vs. Q1: HR 1.46, 95% CI 1.26-1.69) and rwPFS (Q5 vs. Q1: HR 1.18, 95% CI 1.05-1.33). No association was observed with rwTTP (Q5 vs. Q1: HR 1.05, 95% CI 0.90-1.22). Conclusion(s): In this study of real-world oncology data, we demonstrated the use of publicly-available COVID-19 mortality data to measure the time-varying impact of COVID-19 severity on outcomes in pts with advNSCLC. Higher state-level COVID-19 mortality rates were associated with worse rwOS and rwPFS among advNSCLC pts. The association with increased mortality among pts with advNSCLC may be related to COVID-19-related mortality or other factors such as pre-existing comorbidities which were not explored in this study.

Provision of Diet, Exercise, Cholesterol and Hemoglobin A1C Testing in Office Based Medical Visits Among Normal, Overweight, Obese, and Morbidly Obese Individuals in the US

Objectives: Obesity is a global epidemic and leads to complications such as diabetes and dyslipidemia. The objective of this study was to examine the provision of diet, exercise, cholesterol and HbA1c testing in office based medical visits among normal, overweight, obese, and morbidly obese individuals in the US. Method(s): The 2018 National Ambulatory Medical Care Survey data was used to conduct the study. Main outcome was provision of diet/nutrition, exercise, weight-reduction counseling, cholesterol and HbA1c testing in normal (BMI:18-25), overweight (BMI:25-30), obese (BMI:30 - 40), and morbidly obese (BMI:40+) individuals. A logistic regression model was fit to examine main outcomes by BMI status. Survey weights are assigned to the sample visits to obtain national estimates. All models were adjusted for confounders: race, ethnicity, age, gender, MSA, and insurance status. Odds ratios are reported to describe differences in overweight, obese, and morbidly obese patients compared to normal weight patients. Result(s): The weighted study sample consisted of 496,622,621 outpatient visits primarily white (84%), male (58%), covered by private insurance (57%). Multivariate analysis reveals that overweight, obese, and morbidly obese individuals received more HbA1c tests (OR, 1.02;CI, 1.01-1.03;OR, 3.47;CI, 2.31-5.2;OR, 9.01;CI, 4.88-16.66), and lipid profile tests (OR, 1.56;CI, 1.01-2.41;OR, 1.88;CI, 1.32-2.67;OR, 2.16;CI, 1.20-3.90) compared to normal weight patients. Similar trends were observed in the provision of diet/nutrition, exercise, and weight reduction counseling services (OR, 3.31;CI, 1.49 -7.35;OR, 7.51;CI, 2.85 -19.76;OR, 18.47;CI, 7.40- 46.10). Conclusion(s): Our study findings suggest that at risk individuals receive more weight-related services, such as testing for diabetes, cholesterol, diet, exercise, and weight reduction education compared to normal weight individuals. This study forms a baseline to examine disparity in provision of such services post-Covid (2019 and beyond) era given the disruption in the scarcity of health care professionals for such basic preventive services.Copyright © 2023

Report on the Condition of Education 2023. NCES 2023-144

The "Report on the Condition of Education" is a congressionally mandated annual report from the National Center for Education Statistics (NCES). Using the most recent data available (at the time this report was written) from NCES and other sources, the report contains key indicators on the condition of education in the United States at all levels, from prekindergarten through postsecondary, as well as labor force outcomes and international comparisons. There are core indicators that are updated every year and spotlight indicators that provide in-depth analyses on topics of interest to education agencies, policymakers, researchers, and the public. At the broadest level, the Condition of Education Indicator System is organized into five sections: family characteristics;preprimary, elementary, and secondary education;postsecondary education;population characteristics and economic outcomes;and international comparisons. The Report on the "Condition of Education 2023" encompasses key findings from the Condition of Education Indicator System. The full contents of the Indicator System can be accessed online through the website or by downloading PDFs for the individual indicators. [For "The Condition of Education 2023": At a Glance, see ED628291. For the "Report on the Condition of Education 2022. NCES 2022-144," see ED619870.]