Experience of Baricitinib in a Real-World Population with Efficacy and Side Effects: A South London Regional Analysis

Background/Aims Baricitinib is the most common Janus Kinase inhibitor (JAKi) used in the treatment of rheumatological conditions. Whilst randomised controlled trials have demonstrated the efficacy and safety profile of baricitinib, real-world data on the experience of JAKi use in clinical practice is lacking. The aim of this analysis was to evaluate baricitinib use in a real-world patient population in South London. Methods We looked at two rheumatology departments in South London (St George's Hospital;a tertiary teaching centre and Kingston Hospital;a district general hospital). All patients prescribed baricitinib between January 2017 to June 2022 were included. A retrospective assessment of electronic patient notes was performed to evaluate disease activity (determined by DAS-28 scores at baseline, 3-6 months and presently);adverse effects including side effects, rates of and reasons for discontinuation;and prescribing practice, including previous use of other biological disease modifying anti-rheumatic drugs (bDMARDs). Baseline data including age, gender, co-morbidities and rheumatological diagnoses were also included. Results 233 patients were included in this evaluation, with seropositive rheumatoid arthritis being the most common diagnosis (58%) and with a significant female population (87%). Baricitinib improved average DAS-28 scores from 5.75 (range 3.57-8.3) at baseline to 3.23 (range 0.28-7.49) at 3-6 months post-baricitinib, with the most recent DAS-28 score of 2.90 (range 0.56-6.77). Rates of adverse effects were low as shown in Table 1. Baricitinib was discontinued in 60/233 patients, with average duration to discontinuation of 9.5 months. The most common reasons for discontinuation were: ineffective disease control (28/60), recurrent bacterial infection (5/60), deranged liver function (3/60) and venous thromboembolism (2/60). Eight patients died whilst taking baricitinib. Where documented, the causes of death were Covid-19 (4/8) and malignancy (1/8). 110 out of 233 patients had received other bDMARDs before starting baricitinib. Documented reasons for baricitinib choice over tumour necrosis factor inhibitors (TNFi) included: previous lack of response to TNFi (89/233), contra-indication to TNFi (11/233) and preference of oral route (10/ 233). Conclusion Our real-world study of JAKi use shows that baricitinib is efficacious in the treatment of rheumatological conditions. Moreover, baricitinib is well tolerated, with low rates of adverse effects and subsequent discontinuation. (Table Presented).

Current Prescribing Practices in Psoriatic Arthritis - Comparison between the Uk and Europe

Background/Aims Psoriatic arthritis (PsA) is a multi-system disease with a range of management options. Treatment may vary by geographic location. We compared disease characteristics and prescribing practices in the UK and Europe in the post-Covid era. Methods The ASSIST study was a cross-sectional observational study of PsA patients aged 18 years and older selected from 24 centres across 5 countries (UK, France, Germany, Italy and Spain) between July 2021 and March 2022 (IRAS: 287039). Patients attending a face-to-face appointment with a diagnosis of PsA made by a rheumatologist were selected by systematic sampling at each centre and treated in routine clinical practice. Patient and disease characteristics, current treatment and treatment decisions (medications unchanged, switched, added or reduced) were recorded. The analysis was descriptive, with no imputation of missing data. Results 503 patients were included, with arthritis subtype, patient age, disease activity and duration shown (Table 1). Physician- and patient-reported disease severity was highest in the UK, where median patient age was lowest. Conventional synthetic (cs) DMARDS constituted a higher percentage of current PsA treatment in UK than continental Europe (66.4% vs 44.9%), whereas biologic use was more frequent in Europe (68.1% vs 36.4%). Adalimumab was the most commonly used biologic in the UK and Spain. Adalimumab and secukinumab were equally used in Germany, and ixekizumab and adalimumab were joint-first in Italy. Implementing change to the current PsA treatment was most common in the UK, predominantly being a treatment increase. This may reflect the higher level of disease activity or younger patient age in the UK than other countries, as treatment escalation is more likely earlier in the disease course. In the UK, treatment escalation was more commonly achieved by medication addition (26.2%) than medication switch (14%) or dose increase (7.5%). In Europe, medication addition and switch were of more similar frequency (10.9% vs 9.85%). Conclusion Disease characteristics and treatment strategies varied between countries, but particularly between UK and the rest of Europe. In contrast to mainland Europe, csDMARDs predominated in the UK, perhaps reflecting current NICE guidelines. Treatment escalation was most common in the UK, in keeping with higher disease activity. (Table Presented).

Gender disparities in isotretinoin prescribing patterns for pediatric patients before and during the COVID-19 pandemic

Background: Isotretinoin is an effective therapy for severe, recalcitrant, and nodular acne. Due to its teratogenic effects, isotretinoin requires strict adherence to the iPLEDGE risk management program and mandatory lab work. During the COVID-19 pandemic, the U.S. Food and Drug Administration lifted laboratory requirements, accepted remote pregnancy tests, and permitted telemedicine visits. This study examines the impact of reduced in-person evaluation and testing on physician likelihood of prescribing isotretinoin. Method(s): A retrospective review on demographics, acne history, and treatment was conducted on 142 patients <=18 years old who met inclusion criteria. Dates were divided into 1/1/2019-3/16/2020 (pre-MGH COVID shutdown and required in-person lab testing) and 5/25/2020-8/8/2021 (post-MGH COVID shutdown and paused lab testing requirements). Multivariate linear regression with backward elimination and Wilcoxon rank-sum tests were conducted. Result(s): The median number of dermatology visits to isotretinoin initiation was 3 visits pre-COVID and remained 3 visits during COVID (p=0.85). Backward elimination demonstrated gender (p<.0001) and the interaction between gender and acne severity (p=0.042) as significantly associated with increased number of visits before isotretinoin initiation, with female patients requiring more visits than males before starting isotretinoin at every acne severity level. Race, pre- or during COVID, and insurance type were removed as nonsignificant. Discussion(s): Removal of lab mandates during the COVID-19 pandemic did not result in fewer visits to initiation of isotretinoin. Female patients continue to face delays in receiving isotretinoin even with the acceptance of remote pregnancy tests and increased utilization of virtual visits, highlighting the persistent gender disparities in prescribing practices for pediatric patients with acne.Copyright © 2023

Prescriptions For Analgesics For The Treatment Of Osteoarthritis During The Covid-19 Pandemic: A Retrospective Analysis

Purpose: Between 2008 and 2014 approximately 32.5 million adults in the United States reported a diagnosis of osteoarthritis (OA). The 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis (OA) of the hand, hip and knee recommend treating pain due to OA with analgesic therapy as part of multi-modal treatment program. A national survey conducted by the Centers for Disease Control found that patients with OA were likely to delay care during the pandemic. Given this new barrier to healthcare, access to analgesic therapy may have become even more limited. This study aimed to evaluate changes in analgesic prescribing practices for OA as a result of the COVID-19 pandemic. Method(s): A retrospective analysis was performed to identify new prescriptions, number of doses per order and refills of 73 topical and oral analgesics from encounters for OA. OA encounters were identified using 206 ICD-10 codes for OA from July 2019 to June 2021 at UC Davis Hospital and affiliated outpatient centers. Pre-pandemic data corresponds to 2019 data and data collected after this occurred during the pandemic. Counts of new prescriptions, number of doses per order and refills by fiscal quarter were analyzed using a two-factor Poisson Regression with an interaction between quarter and year with corresponding contrasts to detect a difference between 2019 and 2020 as well as 2019 and 2021 and quarters between these years. A follow-up Sidak step-down p-value adjustment was used to correct for type I error. All statistical analyses were done with a two-sided alpha of 0.05. The Poisson Regression was performed with SAS software for Windows version 9.4 (SAS Institute Inc., Cary, NC). Result(s): A total of 31,532 encounters with a primary diagnosis of OA occurred from July 2019 to June 2021. There was an increase in the number encounters with a primary diagnosis of OA (Figure 1) but there was no statistical difference in the medications ordered from 2019 to 2020, 2019 to 2021, and the quarters between these years as well. After adjusting for Type I error, there was a significant decrease in medication refills from 2019 to 2020 (p-value 0.0031, adjusted p-value 0.0425) as well as from 2019 to 2021 (p-value <0.0001, adjusted p-value 0.003) (Figure 2), and there was a significant decrease in number of doses of analgesia from 2019 to 2020 and an increase in number of doses from 2019 to 2021 (p-value <0.0001, adjusted p-value 0.003) (Figure 3). Conclusion(s): The COVID-19 pandemic has persistent impacts on the prescribing practices of analgesics for the treatment of OA. Our data suggests that since the COVID-19 pandemic, patients with OA were overall provided with more doses of analgesics and fewer refills. It is likely that barriers imposed by COVID-19 resulted in these changes in the way analgesics are provided for the treatment of OA. [Formula presented] [Formula presented] [Formula presented]Copyright © 2023

Multi-centre review of systemic anti-cancer prescribing patterns and treatment drop off rates in the United Kingdom 2018-2021

Background: The treatment landscape of metastatic renal cell carcinoma (mRCC) has evolved over recent years with several systemic anti-cancer therapies (SACT) licensed across different lines of treatment. There is ongoing discussion amongst oncology professionals about how best to optimise treatments in terms of sequencing to maximise the potential number of lines or to give the best treatments first. A previous south-west UK audit was completed in 2021 reviewing the drop off rates across 5 UK sites identifying that 69% of patients were able to receive second line therapy and 34% were able to receive third line therapy. Method(s): In this study we conducted retrospective analysis of all patients who commenced treatment with SACT for mRCC between 1st January 2018 and 30th June 2021 in 18 centres across the 4 nations of the United Kingdom. All NHS reimbursed treatment options including the COVID interim treatment guideline options were included. Patients who received SACT as part of a clinical trial were also included. Patients who continued on their respective lines of treatment were censored. We also identified patients who had been on a period of active surveillance before staring SACT in this cohort. Result(s): 1549 patients (71% male: 29% female) were included. IMDC subgroup patients included 21.6%favourable, 52.3% intermediate, 25.1%poor and 1% unavailable. 9.1% of patients had been on active surveillance before starting SACT - defined as a period of longer than 3 months from mRCC diagnosis to starting SACT. Of those patients that started SACT 60.5% of eligible patients had 2nd line therapy, 25.3% had 3rd line, 7.2% received 4th line therapy and only 1% had 5th line therapy. In the 1st line setting 58.9% received single agent VEGF TKI, 24.5% received combination ipilimumab and nivolumab (IO-IO) immunotherapy, 14 % received IO/ VEGF TKI combination and 2.6% received other/trial treatment. The single agent VEGF TKI ratio for 1st line SACT declined year by year with rising IO-IO and IO/VEGF TKI combination ratios seen. In the secondand third-line settings cabozantinib (33.2% 2nd line and 44.4% 3rd line) and nivolumab (32.8% 2nd line and 22.6% 3rd line) were the most common options. Disease progression or death was the most common cause of SACT discontinuation amounting to 57.4%, 62.5% and 79% of SACT cessation in the 1st, 2nd and 3rd lines respectively. Treatment toxicity SACT discontinuation rates were 22.8%, 21.4% and 10.9% for 1st, 2nd and 3rd lines respectively. Conclusion(s): These results suggest that with more treatment options available, including combination/immunotherapy therapies, more patients are able to receive second- and third-line therapies. That said there remains significant drop off rates mostly driven by disease progression that would support the use of our most effective therapies in the upfront setting.

Study of Prescription Pattern of Covid-19 Intensive Care Unit Patients in a Tertiary Care Hospital

COVID- 19 was the most challenging public health problem worldwide for better part of 2 years (2019 - 2021). Although several of the medication have not demonstrated promising benefits in the majority of research, they are nonetheless utilized. The purpose of this study was to compare and contrast the hospital pharmaceutical care of COVID-19 patients by sex, age group, and with regards to oxygen consumption classifying and grouping them with comorbidities seen and auxiliary medication given . Hospital based retrospective observational study was conducted among 123 patients with antigen positive Reverse Transcriptase Polymerase Chain Reaction confirmed COVID- 19 infection admitted in the ICU for 24 hours prior. As the age increased the chance for ICU admission also increased. The most affected age group was above 50 years of age. The total number of patients requiring oxygen was 100% in COVID- 19 ICU patients. Some of the most common comorbidities were heart disease (18%) followed by Diabetes Mellitus (15%) and Hypertension (15 %). Only 48 % of patients received antivirals. Remdesivir which was the mainstay antiviral was given (41%). Amoxicillin and clavulanate combination (Augmentin 625 mg) was the most commonly prescribed antibiotic (27%).The antipyretic of choice was paracetamol which was given to 100% of patients. Almost all patients (78%) were given enoxaparin sodium as the anticoagulant of choice. Regardless of equivocal results, multivitamins and supplements were recommended to all patients. All prescription guidelines as given by ICMR for COVID- 19 ICU patients were followed with the exception of the extensive antimicrobial use.Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

Management of acute genital ulcers, retrospective review of a tertiary Canadian centre and survey of North American Pediatric and Adolescent Gynecology care providers

Background: Acute genital ulcers (AGU) are painful ulcerations of the lower vagina and vulva. Lesions typically occur in adolescents and may be preceded by a viral illness such as Epstein-barr virus, cytomegalovirus and more recently, COVID-19. AGU is a diagnosis of exclusion, with limited data to guide investigations and treatment. We aim to retrospectively review the clinical course of patients presenting to our center with suspected AGU to characterize and evaluate local practice patterns. In addition, we survey pediatric and adolescent gynecology care providers to understand the work up and management of AGU across North America. Method(s): We performed a retrospective chart review between June 1, 2016 to June 30, 2021. Medical records were reviewed to capture demographic data, diagnostic work up and management. Data is presented descriptively, and time to resolution is compared for patients managed expectantly versus with corticosteroids using a Student's T-test. A cross-sectional survey created by study authors was distributed to members of the NASPAG. Data was summarized through descriptive statistics. Management practices between care providers were compared using Fisher's Exact test. Result(s): Overall, 25 patients were diagnosed and managed as AGU at our center during the study period. On average, patients were 13.2 years old (range 11 to 17 years). The majority (92%) reported prodromal symptoms. EBV and CMV were the most ordered serologies (64%);only 3 patients showed serologic evidence of acute viral infection. Conservative measures were recommended to 84% of patients. 40% of patients were prescribed corticosteroids. Average duration to resolution was 16.3 days, with no difference between patients managed supportively versus with corticosteroids (p=0.9). In total, 100 responses from NASPAG members were included. Most care providers reported seeing fewer than 10 patients with AGU per year (62%). Common diagnostic tests performed were herpes simplex virus polymerase chain reaction (82%), Epstein-barr virus serology (56%) and cytomegalovirus serology (47%). Most care providers recommended supportive management with topical analgesia (84%), NSAIDs (83%) and acetaminophen (64%). Topical steroids were considered by 67% based on the degree of accompanying inflammation. There was no difference in corticosteroid prescribing practices between types or location of providers (p > 0.05). Conclusion(s): Our retrospective review and survey capture practice patterns of AGU management amongst pediatric and adolescent gynecology care providers. Further collaboration is needed to prospectively evaluate the effectiveness of treatment modalities, and develop evidence-based guidelines to inform practice.Copyright © 2023

Intrauterine device practices amongst adolescent patients

Background: Adolescent pregnancy is a worldwide public health issue, and the intrauterine device (IUD) has been shown to be a safe and highly effective method of long-acting reversible contraception (LARC) in this group. Patient concerns regarding IUDs are common, which should be addressed during routine office visits. Recently, both Pediatric and Gynecologic societies have recommended the IUD as a first line contraceptive for adolescents given their safety and efficacy. We are hoping to understand current IUD practices amongst providers, elucidate barriers to IUD insertion, and explore whether there have been any changes in IUD insertion patterns since the advent of the COVID-19 pandemic, which has increased telehealth and reduced operating room (OR) availability. Method(s): Survey was disseminated to NASPAG (North American Society for Pediatric and Adolescent Gynecologists) members via the listserv on two separate occasions. Consent was obtained upon completion of the survey. Results from the survey are anonymous. Results were tabulated with descriptive statistics. Ethics approval was obtained (REB22-0269). Result(s): There were 55 respondents, with the majority being Pediatric and Adolescent Gynecologists (71%) from North America (93%). As per providers, adolescents most frequently seek out the IUD for contraception (45%) and menstrual management (42%). Providers felt that the most common barrier to the IUD was misconceptions/myths (67%), as well as pain with insertion (64%). Most practitioners had no change in their IUD prescribing patterns since the start of the pandemic (62%), while some performed more office insertions (11%) and some reduced their IUD practice because of less operative time (15%) and less in-person appointments. Although many physicians perform office insertions, many found that a Procedural Sedation Center facilitated wait times (38%) or felt that such a center would be helpful (33%). Cases being done in the OR were often patients with disabilities/developmental delay (95%) or anxiety (75%). Conclusion(s): Our survey demonstrated that there are still some misconceptions surrounding the IUD. Education on contraception, specifically LARCs, is pivotal in decreasing adolescent pregnancy rates, reducing barriers to IUD use, and improving the attitude of adolescents toward the IUD. Pain with insertion is another limiting factor and a Procedural Sedation Center may be helpful in managing pain expectations and increasing acceptance of the IUD. Although there was no significant change in IUD practices during COVID, a decrease in operating room availability and increase in telehealth may impede IUD prescribing, especially in patients with developmental delay or disabilities who may require insertion in the OR.Copyright © 2023

Post-Decannulation Analgosedation Weaning in Covid-19 Extracorporeal Membrane Oxygenation Patients

INTRODUCTION: COVID-19-associated acute respiratory distress syndrome (ARDS) has necessitated the use of extracorporeal membrane oxygenation (ECMO) to support patients with impaired respiratory function. Reports of increased analgosedation requirements in COVID-19 patients receiving ECMO highlight the possible challenges of weaning analgesia and sedation once these patients are decannulated. METHOD(S): This retrospective cohort analysis investigated analgesia and sedation requirements in COVID-19 and non- COVID-19 patients after venovenous (VV) or venopulmonary artery (VPa) ECMO decannulation. The primary outcome was time to weaning of parental analgosedation. Secondary objectives included incidence of enteral analgosedative use to facilitate weaning of parenteral agents, discharge analgesia and sedative prescribing patterns, and incidence of weaning failure. RESULT(S): A total of 58 patients were included;32 COVID-19 ECMO and 26 non-COVID-19 ECMO patients. There was a higher incidence of prolonged weaning postdecannulation in the COVID-19 group compared to the non- COVID-19 group (59.4% vs. 46.2%, P = 0.43). The median (IQR) time to weaning of all parenteral agents was 8 days (4-13) in the COVID-19 group and 6 days (2-10) in the non- COVID-19 group (P = 0.32). Of all agents, median duration to wean dexmedetomidine was longest in both the COVID-19 and non-COVID-19 groups [9.25 days (3.75-13);4.75 days (2-6.75) (P = 0.15)]. COVID-19 patients had a higher incidence of antipsychotic use to facilitate weaning (88% vs. 65%, P = 0.06) and prescription on discharge (47% vs. 27%, P = 0.17). Approximately 19% of patients in each group experienced failure to wean parenteral analgosedation and required re-initiation of parenteral agents during the postdecannulation period. CONCLUSION(S): Weaning of analgosedation was longer in COVID-19 ECMO patients following decannulation. COVID-19 ECMO patients also required greater addition of enteral therapies to manage analgesia and sedation in the post-decannulation period. Future studies are needed to investigate strategies to optimize sedation in these patients.

COVID-19 and Antibiotic Prescriptions in the United States: A County-level Analysis

Background. Declines in outpatient antibiotic prescribing were reported during the beginning of the COVID-19 pandemic in the United States;however, the overall impact of COVID-19 cases on antibiotic prescribing remains unclear. Methods. We conducted an observational, ecological study to assess the impact of COVID-19 cases and pandemic-related, non-pharmaceutical interventions (NPIs) (e.g., school closures and facemasks) on antibiotic prescribing from February to December 2020 in the US. A random effects panel regression of county-level monthly reported COVID-19 case data and corresponding systemic antibiotic prescription data from IQVIA was used. The model controlled for county demographics, NPIs, and prior years' prescribing. Results. Total antibiotic prescriptions fell 26.1% between March and December 2020 compared to this period from 2017 to 2019. Prescribing rates dropped most among children (Figure 1). A 1% increase in county-level monthly COVID-19 cases was associated with a 0.9% increase (95% CI 0.7%, 1.1%;p< 0.01) in monthly prescriptions dispensed to adults and a 1.2% decrease (95% CI -1.7%, -0.8%;p< 0.01) in prescriptions dispensed to children (Table 1). Counties with schools open for in-person instruction were associated with a 4.4% increase (95% CI 2.3%, 6.4%;p< 0.01) in prescriptions among children compared to counties that closed schools. Internal movement restrictions and requiring facemasks were also associated with lower prescribing among children. Figure 1 A) Total prescriptions per 100,000 population by month (2017-2020). B) Mean prescriptions per 100,000 population for seven age groups (2017-2019 vs 2020). Table 1 Conclusion. Though the number of antibiotic prescriptions in 2020 was lower than previous years, the positive association of COVID-19 cases with prescribing for adults and the negative association for children indicates increases in prescribing occurred primarily among adults. The rarity of bacterial co-infection in COVID-19 patients suggests a large fraction of these prescriptions may have been inappropriate. Facemasks and school closures were correlated with reductions in prescribing among children, likely due to the prevention of other upper respiratory infections (e.g., the cold and influenza). Despite reductions, the strongest predictors of prescribing were prior years' prescribing trends, suggesting the possibility that behavioral norms are an important driver of prescribing practices.

Antibiotic Prescribing Changes in Adults During COVID-19 in Outpatient Patient-Centered Medical Homes (PCMH) in Arkansas

Background. Outpatient antibiotic (OP Abx) prescribing in adults in Arkansas (AR) was among the country's highest in 2019. AR Medicaid analyzed prescription (Rx) claims data and communicated the relative prescribing intensity as an informational metric to each patient-centered medical home (PCMH) beginning in 2020. We describe the Abx prescribing patterns in calendar years 2019 and 2020, during the COVID-19 pandemic. Methods. Data from AR Medicaid paid claims for OP Abx Rxs in adult patients attributed to a PCMH practice for > 6 months were analyzed. Annual Abx Rx claims per 1000 patients were calculated for rural or urban status and by 2019 prescribing rate histories, defined as the low-,middle-, and high-rate prescribers based on 1st, 2nd - 3rd, & 4th quartiles, respectively. The five most common classes in 2019 and fluoroquinolones were explored.A paired t-test, Wilcoxon signed rank test, and one-wayANOVA with post hoc least significant difference test were used to determine statistical significance. Results. 183 PCMHs qualified for analysis. There was a significant decrease in overall annual Abx claim rate, from 1034 to 910 (-12.0%, p< 0.0001). Claim rates decreased in rural (-10.9%, p< 0.0001) and urban areas (-13.3%, p< 0.0001) with no difference between groups (p=0.240). Low-rate prescribers did not change practice from 2019 to 2020, with claim rates of 666 to 665 (-0.2%, p=0.957), while middle- and highrate prescribers decreased, from 1032 to 897 (-13.1%, p< 0.0001), and from 1404 to 1183 (-15.7%, p< 0.0001), respectively. Claim rates significantly decreased for penicillins (-16.0%, p< 0.0001), fluoroquinolones (-15.5%, p< 0.0001), sulfonamides (-13.1%, p< 0.0001), macrolides (-9.9%, p=0.0001), and tetracyclines (-6.3%, p=0.021). First-generation cephalosporins down trended (-7.9%, p=0.111). Conclusion. OP Abx Rx claims significantly decreased from 2019 to 2020 in middle and high-rate prescribers. Low-rate prescribers maintained low Abx Rx claim rates throughout 2020. Future analyses are needed to highlight any rebound effect of Abx prescribing when the pandemic subsides, discerning the informational metric effect versus COVID-19, and informing the next steps for antimicrobial stewardship for PCMHs in AR.

Prescription Pattern for Antimicrobials and the Potential Predictors for Antibiotics among Patients with COVID-19: A Retrospective Observational Study

Introduction: Long-term repercussions of Coronavirus Disease-2019 (COVID-19) on antimicrobial resistance have been raised as a grave concern due to the rampant use of antibiotics in the management of COVID-19. As per meta-analysis, the prevalence of antibiotic prescribing was 74.6% which was significantly higher than the estimated prevalence of bacterial co-infection. World Health Organisation (WHO) recommended that antibiotic therapy should not be used in patients with mild/moderate COVID-19 unless there is any bacterial suspicion. Also, the guidelines laid down by the Ministry of Health and Family Welfare, Government of India, does not recommend systematic empiric antibiotic therapy in patients hospitalised with COVID-19. Despite not being recommended, antimicrobials are still given in clinical practice. Aim(s): To analyse prescriptions for antimicrobials and to identify potential predictors for antibiotic prescription. Material(s) and Method(s): A retrospective observational study was conducted at a tertiary care teaching institute. Data (demographic profile, co-morbidities, disease category, prescribed antimicrobials, laboratory investigations, and duration of hospital stay) were collected from case files of patients with laboratory-confirmed Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) infection. These patients were admitted in the institute from January 2021 to May 2021. Logistic regression was used to analyse factors associated with the empirical use of antimicrobial agents. Result(s): A total of 184 case files were analysed. The mean age of patients was 55.84+/-15.72 years, with a male preponderance (70.10%). Among antimicrobials, antivirals were prescribed in 159 (86.41%) patients, and antibiotics in 152 patients (82.6%). Antivirals prescribed include Remdesivir [109(68.55%)] and Favipiravir [70(44.02%)]. Ceftriaxone was found to be the highest prescribed antibiotic, with a median duration of administration of six days. An association was found between disease severity and CRP level with antibiotic prescription. On multivariable analysis, the odds of receiving antibiotics were 6.7 times higher in patients with severe disease. Conclusion(s): More than 80% of COVID-19 patients received antibiotics. Duration of hospital stay was similar among patients whether they received antibiotics or not. Disease severity and raised CRP level were strong predictors for prescribing antibiotics for COVID-19. Copyright © 2022 Journal of Clinical and Diagnostic Research. All rights reserved.

Between paradigms: Comparing patient and parent experiences of injured adolescents treated at pediatric or adult trauma centres

Background: Injured adolescents may go to pediatric (PTC) or adult (ATC) trauma centres. Although there appears to be little difference in mortality when adolescents are managed in PTCs versus ATCs, evidence suggests differences in clinical processes (e.g., computed tomographic scanning, operative intervention). Moreover, there is little information on nonclinical outcome variation. We aimed to examine differences in nonclinical outcomes of injured adolescents admitted to the lead PTC or ATC within a regional Canadian trauma system. Method(s): After injury-related hospital admission at the PTC or ATC, adolescents (15-17 yr, inclusive) and parents completed the following: the Quality of Trauma Acute Care Patient-Reported (or Parent- Reported) Experience Measure (QTAC-PREM), examining clinical care, information delivery, education and social supports, and opioid exposure;the Pediatric Quality of Life Inventory;and the Brief Symptom Inventory, a psychological distress measure. Data were collected on clinical outcomes and processes. Descriptive bivariate analyses compared outcomes by trauma centre type. Result(s): Twenty-six ATC and 32 PTC patients have been enrolled to date. Survey response rates were 69% (patients) and 75% (parents) at the PTC and 58% (patients) and 54% (parents) at the ATC. There was a similar age and sex distribution between the 2 centres. Injury severity was higher at the ATC, reflected by greater mean lengths of stay (PTC 2.3 d [standard deviation (SD) 2.1 d], ATC 13.3 d [SD 23.7 d]), and lower mean Glasgow Coma Scale scores (PTC 15.0, ATC 13.8) at the ATC. There were also 3 critical care admissions at the ATC and none at the PTC among recruited patients. No differences were observed in patient- or parent-reported clinical care and follow-up experiences. There was also no difference in patient- or parent-reported social and educational support, although subscales were limited by visitor restrictions because of the COVID-19 pandemic, and the majority of injuries occurring during summer months when students were out of school. Parents at the ATC reported fewer opportunities to stay with or near their child compared with those at the PTC (100% v. 69.2%). Parents reported better information provision at the PTC (mean 17.3 [SD 1.3] v. 13.9 [SD 5.2], out of 18 as measured by the QTAC-PREM). Patients and parents were more likely to report receiving opioid prescriptions on discharge at the ATC (55.6% v. 14.3%). There was no difference in quality of life or psychological distress between the PTC and ATC. Conclusion(s): Injured adolescents and their parents indicated similar clinical and follow-up experiences, although parents felt better informed at the PTC and reported better opportunities to stay near their child. Parents and patients reported higher opioid exposures at the ATC. Sharing of communication, accommodation and opioid prescribing practices may allow for improved experiences and reduced opioid exposures in injured adolescents presenting to ATCs. Multivariable analyses are necessary in the future to adjust for injury severity differences..

Prescribing practices in a UK Intensive Care Unit during the first wave of the COVID-19 pandemic

Introduction: Comparatively little is known about drug requirements in patients admitted to ICU with COVID-19 pneumonitis. We analysed drug usage for patients admitted during the first wave of the pandemic, comparing these with a retrospective cohort admitted with Influenza pneumonia. Methods: Forty-nine ventilated patients with COVID-19 pneumonitis were identified through ICNARC, ten were excluded as duration of stay < 7 days or not needing ventilation. Further three were excluded due to missing data and one due to ECMO escalation. Results: The median age was 61 years;length of stay 22 days and 68% survived ICU. Table 1 describes the use of Infusions and enteral medications. Discussion: Propofol was used in most (43% patient-hours in ICU/median duration = 234 hours). All patients received opiate infusions (mainly morphine or alfentanil in similar proportions) and 91% received muscle relaxants, for prolonged periods. Over half received Midazolam (median 106 hours) as an adjunct or substitute to Propofol as patients were difficult to sedate, required longer ventilation, paralysis and concerns with Propofol associated hypertriglyceridemia. Over two-third received alpha agonist infusions (median 68.5 hours) as adjunctive sedation or delirium management. Three quarters of patients received a furosemide infusion (median 90 hours), the evidence extrapolated from studies such as FACTT.1 Around three quarters received Human Albumin (median 100 grams over 3 days). Nearly a quarter received nebulized Prostacyclin for refractory hypoxia, often associated with saturation of HME filters and ventilatory difficulties.2 Over half of patients received Carbocisteine (median 13 days). Clonidine and Risperidone to manage delirium were used in a third (median 10.5 and 11 days respectively), as was Acetazolamide to restore pH and aid weaning. Over a third were prescribed enteral opiates and nearly a quarter received benzodiazepines to manage withdrawal symptoms. Just under a half of patients received Melatonin. Antibiotic usage was high with a median of 3 Antibiotics used (median duration 15 days/61% of patient days). Diagnosing superadded infection such as VAP was challenging3 and we did not routinely monitor serum Procalcitonin levels. We also compared prescribing habits with 12 influenza patients (11 survivors) identified using similar inclusion criteria and found patients with COVID-19 were older (61 versus 51 years ) with longer ICU stays (median 22 versus 20 days). They were also more likely to receive enteral Carbocisteine, Clonidine, Acetazolamide, Morphine and Diazepam. Conclusion: We were able to generate valuable data on prescribing in ventilated patients with COVID-19 pneumonitis during the first wave. Through this, we are able to use drug usage as a surrogate for issues such as delirium, drug withdrawal, antibiotic prescribing and nursing workload in general.

HEALTH PROFESSIONALS' PERSPECTIVES on the USE of JANUS KINASE INHIBITORS to TREAT PATIENTS with INFLAMMATORY ARTHRITIS

Background: Janus kinase inhibitors (JAKi) are relatively new to the feld of rheumatology and provide health professionals in rheumatology (HPRs) with more therapeutic options for treating infammatory arthritis (IA), specifcally rheumatoid arthritis (RA) and psoriatic arthritis (PsA) [1]. Aside from a different target, JAKi differ from often currently prescribed biologics by being administered orally. To date, there is a lack of evidence on what HPRs think about their real-world use and how the COVID-19 pandemic affects JAKi prescription. Objectives: To explore UK-based HPRs' perspectives towards JAKi use in IA patients, and in the context also of the COVID-19 pandemic. Methods: A 15-item anonymous online survey, with both closed and open-ended questions, was designed and piloted on 5 HPRs with amendments made based on their feedback. The survey was advertised on Twitter and shared by email in September 2021. Data were exported from the online survey platform and analysed descriptively with the assistance of statistical software. Results: Fifty-one HPRs responded to the survey: 37 Consultants, 7 Registrars, 5 Clinical Nurse Specialists, 1 Clinical Fellow and 1 'other rheumatology role' (not stated). Responses were received from 11/12 UK regions. Most represented was Greater London (18%) and North-West England (16%). 69% of respondents worked in secondary care, with the remaining 31% in tertiary care. The majority (40%) spent 1-25% of their job role doing research, followed by 27% who were not research active. 60% of HPRs indicated that 1-5% of their RA and/or PsA patients take a JAKi (no HPRs had more than 15% of their RA/PsA patients on a JAKi). 96% of HPRs indicated that they prescribe JAKi in their clinical practice, with 91% of those who prescribe following their local guidelines. 72% of respondents who prescribe JAKi, prescribed them 'frequently' as a monotherapy. Figure 1 shows responses chosen for when JAKi therapy is usually started and for feeling less confdent with JAKi prescription. Of those HPRs who prescribe, 17% have continued JAKi in their patients. When discontinuation occurred, the most common reasons chosen (multiple responses allowed) were 'due to inefficacy' (60%), 'due to other adverse events' i.e., non-major adverse cardiovascular events (32%) and 'due to herpes zoster infection' (28%). 55% of HPRs would consider switching patients to another JAKi after initial failure. Across prescrib-ers, 49% indicated no impact of the COVID-19 pandemic on their prescribing of JAKi. Common reasons chosen for a change in prescribing patterns for JAKi as a result of the pandemic (multiple responses allowed) included: prescribing them more as 'an alternative to infusions, in order to reduce hospital visits' (23%) and as 'an alternative to injections, in order to reduce at-home training visits' (21%). This was followed by 'other reason' (15%) with the free text from all 7 respondents highlighting the benefts of the shorter half-life of JAKi e.g., 'Prescribed more as quick on and quick off so can be discontinued quickly in event of severe infection' (Registrar, Greater London). Safety concerns around the use of JAKi were raised in 13/14 free text comments left at the end of the survey e.g., 'I am concerned about recent reports of increased VTE [venous thromboembolism] and malignancies' (Consultant, Yorkshire and the Humber) and 'Concerns about cardiovascular safety' (Clinical Fellow, Scotland). Conclusion: A large proportion of HPRs indicate confdence in prescribing JAKi to their patients with IA, adhering to local guidelines. JAKi are largely prescribed as monotherapy, with the most frequent reason for discontinuation being ineffi-cacy. The COVID-19 pandemic seems to have positively impacted JAKi prescription, however, safety concerns over JAKi use remain for some HPRs.

COVID-19 impact on multiple myeloma prescribing patterns

Background: COVID-19 has impacted several areas of oncology patient care, most notably the reduction of patient visits for treatments. Standard treatment of multiple myeloma (MM) involves a combination of intravenous (IV) and oral therapies. The purpose of this study is to assess the impact COVID-19 had on IV and oral medication prescribing patterns pre and during the COVID-19 pandemic among MM patients. Methods: This is a retrospective review of adult MM patients insured by a large commercial and Medicare health plan in the United States who started a new IV or oral MM agent during the study period. To assess the impact of COVID-19 on IV and oral medication prescribing patterns, we compareda pre-COVID period (March 1-August 31, 2019) to a COVID period (March 1-August 31, 2020). We utilized medical and pharmacy claims to identify patients and calculated new therapy starts per newly diagnosed patient (defined as the number of patients starting a new IV or oral medication for MM divided by the total number of patients with a first indication date of MM within the study timeframe). We compared rates using a Chi-square test;p-values ≤ 0.05 were considered statistically significant. Results: 1,754 patients were enrolled in the study;there were no significant differences in demographic characteristics pre and during COVID-19 between the two groups with respect to age (67.05 vs. 66.64;p=0.45), gender (p=0.80), insurance plan type (p=0.17), geographical region (p=0.26) and medication (p=0.59). During COVID-19, the number of newly diagnosed MM patients decreased by 22% (9,657 to 7,560) and the total number of new therapy starts decreased by 11% (930 to 824). When looking at rates of new therapy starts per newly diagnosed patient, both IV (11%;p=0.03) and oral (51%;p=0.03) medication rates significantly increased. Additionally, there were significant increases in new therapy start rates by region in the Northeast for oral (157%;p<0.01) and West for IV (32%;p=0.02) medications. There were no significant differences in new start rates by insurance plan type (all p>0.08). Conclusions: While the total count of new therapy starts, a proxy for new diagnoses, decreased during COVID-19, the rate of new starts for both IV and oral therapies for patients diagnosed with MM significantly increased. These increased start rates may be explained by a remarkable 22% drop in the total number of newly diagnosed MM patients during COVID-19. As the pandemic continues, further study is warranted to understand how COVID-19 may impact IV vs. oral usage in MM.

Impact of COVID on Antibiotic Prescribing Patterns in a Medicaid Population

Introduction: In 2020, the COVID pandemic altered care patterns throughout health care. Routine office and ER visits declined and antibiotic prescribing changed as a consequence. Research Question or Hypothesis: How did the COVID pandemic affect outpatient antibiotic prescribing in an Arkansas Medicaid population? Study Design: Descriptive statistics were used to determine the impact of the COVID pandemic on outpatient antibiotic prescribing in Arkansas Medicaid patients. Methods: Antibiotic pharmacy claims were extracted from the Arkansas Medicaid prescription claims database for calendar years 2018 through 2021. The monthly total number of antibiotic claims from January 2018 through December 2021 were calculated. Monthly data from 2018 and 2019 were averaged to create a baseline. The average percent change in the number of outpatient antibiotic claims from February 2018-2019 to April 2018-2019 was compared to the percent change from February 2020 to April 2020. Additional percent change was calculated as the difference between the 2018-2019 average percent change and the 2020 observed percent change among all ages and prespecified age-groups. Results: The seasonal (February-April) drop in antibiotic prescriptions pre-pandemic was -18%, from 52,000 to 42,750 per month. In February-April 2020, claims fell an additional 42% (-60% in 2020, from 49,020 to 19,640). Age-related decreases showed claims for patients <5 years dropped an additional 54% from baseline;5-17 years, 48%;and >18 years, 20%. Antibiotic prescriptions in April 2021 (∼34,000) rebounded to approach the pre-pandemic baseline of 42,750. Conclusion: Outpatient antibiotics prescription claims declined sharply from baseline, especially in children, in 2020 during the COVID pandemic. Potential reasons may be attributed to clinic avoidance, more viral than bacterial illnesses, or less illness due to masking and distancing;however, the degree attributed to each has not been determined. A return to baseline was observed in 2021. Continued efforts in antibiotic stewardship are warranted.

Obesity Care in Adolescents: Are We Screening for Comorbidities and Providing Anti Obesity Medications?

Background: In the United States, obesity impacts the health of over 20% of adolescents. As more data emerges on obesity and the associated adipose tissue dysfunction, updated screening and treatment guidelines for obesity and its related comorbidities have been published. (See Table 1). However, it is unclear if providers are adhering to these guidelines. Methods: We leveraged the TriNetX Research Network platform, a global federated network of electronic medical record data, to identify current national practice patterns for screening for lipid dysfunction, liver function abnormalities, and insulin resistance, and prescribing of anti-obesity medications. Additionally, we reviewed the prescription patterns of FDA approved and offlabel anti-obesity medications. Our cohort was defined as patients 14-18 years old, with three outpatient encounters between Jan 1, 2017 and March 1, 2020, and obesity, defined as BMI>30 or greater than the 95th percentile recorded on 3 separate outpatient encounters. The date cutoff was set in order to avoid the potential confounding effects of COVID-19 global pandemic. Exclusion criteria included a diagnostic code for lipid dysfunction, fatty liver, or insulin resistance prior to Jan 1, 2017 as well as any diagnosis of type 1 Diabetes. Screening for comorbidity of lipid dysfunction, fatty liver, and insulin resistance were defined by the presence of a total cholesterol, ALT, and Hgb A1C respectively. Results: The cohort included 31,017 patients that met all inclusion and exclusion criteria. The mean age of patients was 16. 56% of patient had an ICD-10 code of obesity in the chart. Screening rates for lipid dysfunction (Total Cholesterol), insulin resistance (Hgb A1c), and fatty liver (ALT) were 44%, 54%, and 41% respectively. Only 31% of patients were screened for all 3. When screened, 28% of patients had a Hgb A1C >5.7%, 22% had an ALT >45, and 13% had a total cholesterol >200. 9% of patients had prescriptions of anti-obesity medication including (Orlistat, Phentermine, Topiramate, Metformin, Liraglutide). The two most used medication were Metformin and Topiramate. However, when excluding individuals with ICD-10 codes for migraines (G40, G43, G44), prevalence of topiramate prescription decreased from 4% to 1%. Conclusion: Screening for obesity comorbidities continues to fall short of recommendations. Screening rates in our study occurred at about the same rates as previously reported in the literature (50- 60% for diabetes, 38-40% for lipid dysfunction, and 2-56% for liver disease). There is evidence to support the use of antiobesity medications in pediatric patients;however, we found that anti-obesity medication prescriptions remain limited nationally. To our knowledge, this is one of the largest studies to evaluate this issue in children. Further studies are warranted to explore the causes of low screening and treatment rates in adolescents with obesity and inform interventions.