Prevention of Venous Thromboembolism in IBD Patients May Not Be Associated With Prophylaxis Rates

Introduction: Patients with inflammatory bowel disease (IBD) harbor a higher risk of deep venous thrombosis and venous thromboembolism (VTE) compared to healthy individuals. Previous studies, including a large meta-analysis, estimate the risk of VTE incidence to be almost 2-3 times baseline. Guidelines, therefore, recommend VTE prophylaxis in most inpatients with IBD. While previous studies have demonstrated less than ideal adherence with these guidelines, we sought to determine the rate of VTE prophylaxis at an academic medical center. Method(s): A retrospective chart review of inpatients with Crohn's disease or ulcerative colitis admitted to a tertiary medical center in Bronx, NY from 1/2015 to 2/2020 was performed. All patients who were admitted with a primary gynecological or psychiatric disorder, COVID infection, or known hypercoagulable disorder were excluded. Orders for pharmacologic and mechanical VTE prophylaxis at any point during the patient's admission were ed. Using ICD10 codes, IBD patients with acute VTE variations were identified. Clinical and demographic variables were analyzed for their association with VTE prophylaxis. Two-sample t-tests and Fisher's exact tests were used as appropriate. A p-value < 0.05 was considered statistically significant. Result(s): A total of 1670 patients with IBD were identified among whom 1280 (76.7%) were prescribed either pharmacological or mechanical VTE prophylaxis during their hospital admission. 70 patients were excluded from the analysis of development of VTE because their diagnosis of VTE was prior to their admission date. Older age (p<.0001), higher BMI (p<.0001), female sex (p=.001), havingMedicare insurance (p<.0001) were associated with VTE prophylaxis ordering (see Table). There was a VTE incidence of 6.2% (n=98/1600) of the IBD patients in our cohort, with 3/388 patients (0.8%) not being prescribed prophylaxis and 95/1212 (7.8%) being prescribed prophylaxis (p< 0.001). Conclusion(s): Contrary to other studies, we show that VTE prophylaxis rates may not be associated with a reduction in VTE incidence during hospitalization. While bias by indication may be contributing to this finding with those at greatest risk more likely to receive prophylaxis, other factors may be involved. Further studies are warranted. (Table Presented).

Clinical epidemiology of COVID-19 in Black people with HIV in south London, UK

Background: The COVID-19 pandemic disproportionally affected Black communities who were at greater risk of SARS-CoV-2 acquisition, morbidity, and mortality than those of White ethnicity. We describe the clinical epidemiology of COVID-19 in the GEN-AFRICA cohort of Black people with HIV in two South London clinics. Method(s): First reported episodes of COVID-19 up to 12/2021 were ascertained by direct questioning and/or medical records review. The cumulative incidence of COVID-19 and vaccination was determined by Nelson- Aalen methods. Pre-pandemic immunovirological and comorbidity status obtained prior to 01/2020 was used to identify risk factors for COVID-19 using Cox regression. We compared characteristics of participants with mild/ moderate (not requiring hospitalization) and severe (requiring hospitalization or resulting in death) COVID-19. Result(s): COVID-19 status was available for 1184 (95%) of 1289 GEN-AFRICA participants (mean age 49.1 years;55% female;median CD4 565;93% HIV RNA <200), and SARS-CoV-2 vaccination status for 1160;998 (86%) had received at least one vaccine dose (administered to 50% by 16/02/2021). A total of 310 participants (26.2%) reported a first episode of COVID-19 (any severity), with a cumulative incidence of 6%, 14%, 15% and 22% following the initial, alpha, delta, and omicron waves. Women, people of East African ancestry, and those with detectable HIV RNA were more likely to report COVID-19 (Table). CD4 (current/nadir), class of antiretroviral therapy (ART), and comorbidity status were not associated with COVID-19. Findings were similar when restricted to episodes in 2020 (prior to vaccine availability) or testconfirmed COVID-19. Severe COVID-19 cases (N=34) were more often male (p=0.002), of West-African ancestry (p=0.01), with lower CD4 cell counts (p=0.002), and they more often had a history of AIDS, diabetes mellitus, cardiovascular disease, and chronic kidney disease (all p=0.001) compared to mild/moderate cases;they were also more likely to be on protease inhibitor (PI)- containing ART (p=0.01). Conclusion(s): By the end of the second year of the pandemic, 22% of black people with HIV in South London had experienced COVID-19. Immune and comorbidity status were not associated with COVID-19 when all cases were considered but strongly associated with severe COVID-19 disease, as were West-African ancestry and being on a PI. (Table Presented).

Evaluating the Impact of Nutrition Support on Clinical Outcomes in Critically Ill Patients With COVID-19: A Retrospective Study

Background: Patients with COVID-19 experience prolonged ICU stays. The rate of malnutrition in hospitalized patients remains controversial as well as the appropriate nutrition therapy for these patients. The purpose of the study was to evaluate the impact of nutrition support on clinical outcomes in critically ill patients with COVID-19. Method(s): This was a retrospective chart review involving 48 adults, critically ill patients admitted with confirmed SARS-CoV-2 infection. Data extracted included demographic, anthropometric, medical history, biochemical tests, medications, nutrition support protocol, clinical outcomes, length of stay, and ventilator status. We tested associations between aspects of nutrition support (such as early versus delayed feeding, adequacy, and patient positioning) and clinical outcomes (ICU length of stay, weight status, malnutrition status, refeeding syndrome, and ventilator days) using Chi-square, and t-tests, with significance established at the level of p <= 0.05. Result(s): Thirty-eight percent (18) of the patients met the criteria for malnutrition using the Global Leadership Initiative on Malnutrition (GLIM) tool. Approximately 83% of these patients did not have a documented diagnosis of malnutrition in the electronic medical record. More than half of the patients in the study (58.3%) were placed in prone position as part of their treatment and only 7% of these had documented signs of feeding intolerance. None of the patients were switched to total parenteral nutrition (TPN). Only 37% of the patients received adequate protein within the first week of nutrition support while 98% had adequate or exceeded caloric needs. There was no difference in percent weight loss among patients who received inadequate protein compared to those who had adequate protein. Inadequate protein intake was associated with shorter ICU stays (p = 0.04) and fewer ventilator days (p = 0.01) compared to those with adequate protein. Patients who received inadequate or exceeded their calories needs also had shorter ICU stays and fewer ventilator days (p > 0.05). In the context of this study, shorter ICU stays translated into fewer days of life, as 98% of the studied population died before ICU discharge. There were no associations between early nutrition support and selected biochemical parameters. Conclusion(s): The rate of malnutrition was remarkable and largely undocumented. Most patients did not meet the minimum estimated protein needs. Studies with larger sample sizes are needed to examine appropriate protein needs and the effect of nutrition support in patients with COVID-19. Diagnosing and documenting malnutrition warrants heightened attention.

Clinical Effectiveness and Adverse Events of Adjunctive Remdesivir Administration Vs Standard of Care in Adults with Severe and Critical Covid-19

Intro: The unavailability of specific treatment for COVID-19 prompted the empirical use of remdesivir, a viral RNA polymerase inhibitor. Since evidences present conflicting results, this study aims to determine the clinical effectiveness and adverse events of adjunctive remdesivir administration vs standard of care (non-remdesivir) in COVID-19 adult patients in a tertiary hospital in Baguio City, Philippines. Method(s): We performed a single-center, retrospective study of severe to critical COVID-19 patients admitted from September 2020 to September 2021. Stratified random sampling was employed and data collection was through chart review. Analysis was done with R Statistical Software version 4, utilizing paired T-test and McNemar test, with p-value of <0.05 considered as significant. Finding(s): A total of 318 patients were reviewed and classified into the remdesivir (n=159) and standard of care (non-remdesivir) (n=159) groups. Baseline characteristics were comparable except for co-morbidities (p<0.05). There were no noted significant differences between both groups in terms of morality (p=0.885) and reduction in chest radiograph infiltrates (p=0.182). However, the average number of days to clinical improvement (7 days vs 12 days) and recovery (16 days vs 21 days) were statistically lesser in the remdesivir group (p=0.00). Also, those who experienced diarrhea (p=0.33) and transaminitis (p=0.003) were significantly higher in those given remdesivir. Conclusion(s): There was no significant difference in terms of mortality in those given remdesivir vs standard of care alone. Nevertheless, remdesivir administration is associated with significantly faster time to clinical improvement and recovery. The drug is thought to facilitate faster lung viral load clearance and improved pulmonary function through inhibition of RNA polymerase. Though not potentially life-threatening, the drug may cause diarrhea and elevation in transaminases.Copyright © 2023

Are Biopsies Sufficient for Diagnosis Comparison of ESD and Forceps Biopsy Findings for Colon and Rectal Lesions

Introduction: Endoscopic submucosal dissection (ESD) is a minimally invasive technique used for removal of superficial dysplastic or early cancerous colon and rectal lesions. For larger lesions ( .20mm) that are not amenable to endoscopic mucosal resection, superficial biopsies are typically taken prior to referral for ESD. The aim of this study was to evaluate the degree of concordance between superficial forceps biopsies and ESD pathology. Method(s): A retrospective medical record review was performed including consecutive patients who underwent ESD of colon and rectal lesions at a tertiary care center between 10/2018 and 11/2021. Pathology results from outside hospital and same institution pre-ESD superficial forceps biopsies were compared to ESD pathology results. The primary outcome was the number of patients found to have higher disease severity on ESD pathology compared with superficial forceps biopsies. Result(s): Of the 84 patients who underwent ESD of colon or rectal lesions, 72 had pre-ESD superficial forceps biopsies which were taken at an outside hospital (n=48) or at the same institution (n=36). The average length of time between outside hospital superficial forceps biopsies and ESD was 91 days compared to 75 days for those performed at the same institution. Delays between superficial forceps biopsies and ESD may be related to the COVID-19 pandemic prolonging time between procedures. Pathology findings after ESD differed from superficial forceps biopsies in 31/72 patients (43%) with 21 patients receiving upgraded disease severity and 6 patients receiving a new cancer diagnosis based on ESD pathology. Patients who received a new cancer diagnosis had more days between superficial forceps biopsies and ESD compared with the whole cohort (86 vs 75, respectively). Conclusion(s): While superficial forceps biopsies of colon and rectal lesions were typically concordant with ESD pathology, 29% of patients in this cohort received upgraded disease severity based on ESD pathology. This shows that while superficial forceps biopsies can aid in diagnosis, en bloc resection via ESD remains critical for accurate diagnosis of large colon and rectal lesions. These results also show that ESD is not only diagnostic but therapeutic given 75% of the patients in this cohort achieved R0 resection.

Opportunities for Virtual Care in Eosinophilic Esophagitis: Real-World Dietary Therapy Practice

Introduction: Dietary therapy for eosinophilic esophagitis (EoE) is an effective first-line treatment aimed at identifying triggers by systematically removing then reintroducing food groups. Success on diet therapy can be augmented by working with a dietitian, but this is not a universal clinical resource. Virtual or telehealth approaches to nutrition care may offer opportunities to implement diet therapy for EoE. We conducted a retrospective study at a tertiary center with six GI dietitians to compare real-world standard in-person versus virtual EoE nutrition practices in terms of access, follow-up< and disease control. Method(s): We identified adults with EoE referred to GI nutrition through query of the electronic medical record by ICD-10 diagnoses and confirmed by chart review. As all nutrition visits prior to the COVID pandemic were performed in-person, standard care was defined as care established in January-December 2019 and virtual care in January-December 2021. Associations were analyzed using Chi-squared and Student's t test (Table). Result(s): A total of 204 patients were included;99 referred for standard in-person and 105 virtual nutrition care. The cohorts did not differ significantly by gender, age at the time of referral, race, and distance lived to our center. Of these, 55.6% (55) standard and 48.6% (51) virtual visits were completed with a dietitian (p=0.341) and 4-food elimination diet was the most commonly planned diet. The majority initiated the diet (80.0% standard, 78.4% virtual, p=0.842) and among them, half successfully attained histologic remission with the elimination phase (63.6% standard, 47.5% virtual, p=0.324). Ultimate treatments plans included remaining on dietary therapy (25.5% standard, 23.5% virtual, p=0.728), no treatment or lost to follow-up (34.6% standard, 25.5% virtual), and medication (25.5% standard, 41.2% virtual). Conclusion(s): There is a growing demand for nutrition care in EoE and in our tertiary practice, we found no differences in the success and response rate on elimination diet or follow-up between patients receiving standard or virtual nutrition care. Virtual approaches to implementing EoE dietary therapy may serve to complement in-person care and offer opportunities for those lacking local dietitian access. However, up to one-third of patients are lost to follow-up or remain untreated, also highlighting a need to identify, understand, and overcome barriers to treatment uptake and disease control .

Factors associated with severe SARSCOV- 2 infection in people of Black ethnicities living with HIV in the UK

Background: The COVID-19 pandemic has disproportionally affected people of black ethnicities, who have been at greater risk of SARS-CoV-2 acquisition, morbidity and mortality than those of white ethnicity. We describe factors associated with severe COVID-19 infection in the GEN-AFRICA cohort of people of black ethnicities living with HIV in the U.K. Method(s): First reported episodes of COVID-19 up to October 2022 were ascertained by direct questioning and/or medical records review. Pre-pandemic immune-virological and comorbidity status was based on measurements obtained prior to 01/2020 and used to identify risk factors for severe (requiring hospitalisation or resulting in death) COVID-19, using logistic regression Results: COVID-19 status was available for 1806 (72%) of 2503 GEN-AFRICA participants (mean age 49.2 [SD 10.2] years;56% female;80% sub-Saharan African and 14% Caribbean ancestry, median CD4 count 555 [IQR 400-733] cells/mm3;93% undetectable HIV RNA [<200 copies/ mL]);573 (32%) reported a clinical illness consistent with COVID-19;63 (3.5%) experienced severe COVID-19 (hospitalisation 59;death 4). Those who experienced severe COVID-19 were older, more often male, had lower CD4 counts and fewer had undetectable HIV RNA;they more often had prior AIDS, hypertension, diabetes mellitus and chronic kidney disease. Region of ancestry, nadir CD4 count, and obesity were not associated with severe COVID-19. In multivariable analysis, CD4 count <350 cells/mm3, diabetes mellitus and chronic kidney disease were associated with increased odds of severe COVID-19 (Table). Sex and a pre-pandemic HIV RNA were associated with severe disease although this did not reach statistical significance. By October 2022, 1534 (88%) of this sample had received >=1 dose of SARS-CoV-2 vaccine;those who experienced severe COVID-19 were less likely to report vaccination (77% vs. 89%, p=0.01). Conclusion(s): By the end of October 2022, nearly onethird of people of Black ethnicities with HIV in this sample had experienced COVID-19;3.5% had developed severe COVID-19 disease. Pre-pandemic immunovirological and comorbidity status were associated with severe COVID-19. Black populations with less favourable HIV control than observed for GEN-AFRICA participants may have suffered greater COVID-19 morbidity and mortality. (Table Presented).

Impact of Covid-19 Infection on Baseline Autonomic Symptoms in Patients with Pre-Existing Postural Tachycardia Syndrome and Orthostatic Intolerance

Background: Recently there have been several published case series of some survivors of COVID-19 infection left with chronic symptoms of autonomic dysfunction (AD) with features of orthostatic tachycardia syndrome (POTS). However, the impact of this viral illness on the underlying autonomic symptoms has not been studied in the patient population who have a pre-existing POTS diagnosis and are receiving treatment. Objective(s): So far, the impact of this viral illness on the underlying autonomic symptoms has not been studied in patients with a pre-existing POTS diagnosis and receiving treatment. Our study aims to report the impact of a COVID-19 infection on these patient populations, both during the acute phase of the disease and post-recovery. Method(s): Our Institution Review Board (IRB) approval was obtained to access charts of the study subjects. Basic demographic and diagnosis details including the age, sex, prominent symptoms, duration of POTS diagnosis, medications, associated autonomic disease, and medication regimen were obtained from the retrospective chart review. Additional information regarding COVID-19 infection, course of illness, need for hospitalization, worsening of POTS symptoms, need for ED visits, improvement with the escalation of therapy, the type of persisting symptoms, and vaccination status were obtained from both chart review and details from the patients during the scheduled office visit. Result(s): A total of 49 patients were studied. About 42 patients (82 %) had the alpha-variant infection before the vaccines were available. 28% (14 patients) of them had tested positive for infection more than once (i.e infection with alpha, delta, or omicron variant). About 38 (92.7%) of them reported having worsening of their baseline POTS symptoms during the active infection phase. About 28 patients (57 %) experienced worsening of their dysautonomia symptoms for at least 1-6 months post-infection. Nearly 30 patients (73.2%) required additional therapy for their symptom control and improvement. Conclusion(s): Of subjects with pre-existing POTS, most experienced a worsening of their baseline autonomic symptoms after suffering the COVID-19 infection which required additional pharmacotherapy for their symptom improvement. The majority of them had recovered within 6 months of therapy. From our observation, it is evident that the COVID-19 infection exacerbates the underlying symptoms in patients with established POTS disease.Copyright © 2023

The Association of Inflammatory Marker Levels on Severity of Infection and in-Hospital Mortality among Covid-19 Confirmed Patients

Intro: COVID-19 is a respiratory and systemic disease with varying severity, caused by SARS-CoV-2 virus. The pathophysiology of COVID-19 has been postulated to be due to a release of pro-inflammatory cytokines causing cytokine storm. Several inflammatory markers have been studied to prognosticate the course of the disease but with varying results. Baseline inflammatory marker levels may be helpful in early recognition of disease severity which may translate to early aggressive treatment and better outcomes. The objective of this study is to determine the association of the initial levels of procalcitonin, CRP, LDH, Ferritin and D-Dimer on severity of infection and in-hospital outcomes among COVID-19 confirmed patients admitted at Our Lady of Lourdes Hospital Methods: A total of 238 subjects admitted from March 2020-June 2021 were included. Chart review was done and demographic and laboratory data were obtained. Subjects were categorized by disease severity and outcome. SASTM On Demand was used for data analysis: ordinal logistic regression to determine the association of initial inflammatory marker levels on the severity, while Binomial logistic regression to determined the association on the in-hospital outcome. Null hypothesis was rejected at 0.05-alpha level of significance. Finding(s): The study showed a significant association between LDH and severity of infection (p-value 0.014, Risk ratio 1.002), as well as on mortality (p-value 0.004, Risk ratio 1.003). There was no significant association between procalcitonin and severity of infection but there was significant association between procalcitonin and mortality. No significant association was noted between CRP, Ferritin and D-Dimer with severity of infection nor mortality. Conclusion(s): Patients with higher LDH levels were more at risk of severe and/or critical COVID-19 and in-hospital mortality. There was also significant association in the PCT levels and mortality but not with disease severity. There was no significant association between ferritin, D-DimeCopyright © 2023

Diarrhea as an Independent Risk Factor for COVID-19 Severity and Inpatient Mortality

Introduction: Multiple meta-analyses have shown that over 15% patients with COVID-19 have at least one gastrointestinal complaint, most commonly diarrhea. The effects on the gastrointestinal system are thought to be mediated by the high expression of angiotensin-converting enzyme 2 (ACE2) and cellular serine proteases (TMPRSS2) in enterocytes, which cause altered intestinal permeability. The purpose of this study was to determine the incidence of diarrhea as it relates to COVID-19 infection and to determine if having concomitant diarrhea had a significant impact on disease course. Method(s): A retrospective chart review of 164,730 patients in a hospital system who were older than 18 years of age and had a positive SARS-CoV-2 test from March 2020 to February 2022 was completed. Diarrhea was determined using ICD code or patient's symptoms. Patients with confounding variables such as IBD, IBS, Celiac, Clostridium difficile, and pancreatic insufficiency were excluded. Demographic clinical characteristics and outcomes, including inpatient admission and mortality, were compared in patients with and without diarrhea. The Mann-Whitney test and Fisher's exact or Chi-square test was used for continuous and categorical variables respectively and multivariate logistic regression was used to evaluate for significant differences in disease outcome between the two groups. (Table) Results: Of the 164,730 patients included, 14,648 (8.89%) had diarrhea at the time of SARS-CoV-2. 6,748/33,464 (20.16%) of inpatient admissions were associated with diarrhea. On multivariate analysis, diarrhea was an independent risk factor for inpatient hospitalization (OR 2.39, CI 95% 2.28-2.51, P, 0.001) and inpatient mortality (OR 1.15, CI 96% 1.06-1.26, P= 0.001) after controlling for age, gender, race, comorbidities that could impact patient outcome, use of immunomodulators and outpatient antibiotics. Conclusion(s): These findings show that, even with controlling for comorbidities with COVID-19, diarrhea was an independent factor for predicting inpatient mortality and inpatient admission in general. Patients who had diarrhea and COVID-19 were sicker, having more comorbid conditions than those without diarrhea in our cohort. Attention should be given to not only respiratory complaints of COVID-19, but also gastrointestinal complaints, as they are an indicator of poor prognosis and mortality.

Knowledge About Preventive Health Guidelines for Inflammatory Bowel Diseases in Patients: A Quality Improvement Project

Introduction: Preventive care guidelines for patients with Inflammatory Bowel Disease (IBD) emphasize the need for a patient-centered interdisciplinary approach, with assessment and management of the patient's physical and mental health as well as the IBD. There is no data about compliance with current IBD preventive care guidelines in Puerto Rico. This study aims to evaluate current IBD preventive care in the clinic, and knowledge among patients and gastroenterologists about the preventive care guidelines. The 3-phase study includes retrospective medical record review, an anonymous online survey of gastroenterologists, and an anonymous survey of patients. We report the results of the patient survey. Method(s): Adult patients with an established diagnosis of at least 6 months of ulcerative colitis (UC), Crohn's disease (CD) or indeterminate colitis (IC), were recruited from the IBD Clinics and through IBDrelated social media. Questionnaires were filled in the clinic and online using Google forms. Statistical analysis was performed using descriptive statistics. Comparisons of proportions and means between groups was based on Fisher's exact and chi square tests. The study was approved by the MSC IRB. Result(s): 83 patients completed the survey, 42 from the clinics and 41 through social media. 60% had CD, 47.4% were diagnosed more than 10 years ago, 57.9% were younger than 38 years old and 68% were on immunosuppressants/biologics. 83.13% and 60.24% of patients knew that COVID and Influenza vaccines were indicated, respectively. However only 42.17%, 36.14%, 32.53% and 31.33% of patients knew about indications for HPV, pneumococcal, varicella and zoster vaccines, respectively. There was a significant difference about knowledge regarding screening for latent TB (p=0.019), anxiety and depression (p= 0.03) and smoking status (p=0.033) between CD and UC/IC patients, as shown in Table. Conclusion(s): Our study showed a significant lack of knowledge about IBD preventive care in patients. Strategies to improve patient education are needed. The results of the review of records from the clinic as well as the knowledge of gastroenterologists will point out other deficiencies in the healthcare system and help design methods to improve patient care. Another aspect that needs to be explored is access to preventive measures such as vaccines. (Table Presented).