Pre-appendectomy hyponatremia is associated with increased rates of complicated appendicitis

Background

Acute appendicitis is one of the most common surgical emergencies worldwide. Preoperative assessment of the risk of complicated appendicitis may aid in treatment planning. We sought to investigate the association between pre-appendectomy hyponatremia and diagnosis of complicated appendicitis.

Methods

The TriNetX platform, a federated health research network that aggregates de-identified electronic health record data of over 90 million patients across the United States, was queried for patients who underwent appendectomy starting January 2019 and who had at least one sodium value from the preoperative period. The study population was stratified into three age groups: pediatric (age < 18), adult (age 18-64), and older adult (age ≥ 65). These groups were subdivided into patients with preoperative hyponatremia (<135 mmol/L) and normonatremia (135-145 mmol/L).

Results

Among the 61,245 patients who met inclusion criteria, 17,546 were included for analysis following propensity score matching. The odds of complicated appendicitis were highest in pediatric patients (age < 18) with pre-appendectomy hyponatremia (odds ratio [OR] = 2.91, 95 % CI [2.53, 3.35]). Patients age 18-64 and aged ≥ 65 with preoperative hyponatremia also demonstrated increased odds of a complicated appendicitis diagnosis, but to a lesser extent (OR = 2.11, 95 % CI [1.92, 2.32] (OR = 1.49, 95 % CI [1.25, 1.77], respectively).

Conclusions

In a large analysis of matched patients with acute appendicitis, we found an association between immediate preoperative hyponatremia and complicated appendicitis. Future studies are indicated to further evaluate the role of hyponatremia as a potential diagnostic marker for complicated appendicitis in all age groups.

Key message

This study suggests a role of hyponatremia as one of multiple variables to incorporate into future clinical decision tools for complicated acute appendicitis.

Drug repurposing for reducing the risk of cataract extraction in patients with diabetes mellitus: integration of artificial intelligence-based drug prediction and clinical corroboration

Diabetes mellitus (DM) increases the incidence of age-related cataracts. Currently, no medication is approved or known to delay clinical cataract progression. Using a novel approach based on AI, we searched for drugs with potential cataract surgery-suppressing effects. We developed a drug discovery strategy that combines AI-based potential candidate prediction among 2650 Food and Drug Administration (FDA)-approved drugs with clinical corroboration leveraging multicenter electronic health records (EHRs) of approximately 800,000 cataract patients from the TriNetX platform. Among the top-10 AI-predicted repurposed candidate drugs, we identified three DM diagnostic ICD code groups, such as cataract patients with type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus (T2DM), or hyperglycemia, and conducted retrospective cohort analyses to evaluate the efficacy of these candidate drugs in reducing the risk of cataract extraction. Aspirin, melatonin, and ibuprofen were associated with a reduced 5-, 10-, and 20-year cataract extraction risk in all types of diabetes. Acetylcysteine was associated with a reduced 5-, 10-, and 20-year cataract extraction risk in T2DM and hyperglycemia but not in T1DM patient groups. The suppressive effects of aspirin, acetylcysteine, and ibuprofen waned over time, while those of melatonin became stronger in both genders. Thus, the four repositioned drugs have the potential to delay cataract progression in both genders. All four drugs share the ability to directly or indirectly inhibit cyclooxygenase-2 (COX-2), an enzyme that is increased by multiple cataractogenic stimuli.

Disrupted seasonality and association of COVID-19 with medically attended respiratory syncytial virus infections among young children in the US: January 2010-January 2023

Respiratory syncytial virus (RSV) infections and hospitalizations surged sharply in 2022 among young children. To assess whether COVID-19 contributed to this surge, we leveraged a real-time nation-wide US database of electronic health records (EHRs) using time series analysis from January 1, 2010 through January 31, 2023, and propensity-score matched cohort comparisons for children aged 0-5 years with or without prior COVID-19 infection. Seasonal patterns of medically attended RSV infections were significantly disrupted during the COVID-19 pandemic. The monthly incidence rate for first-time medically attended cases, most of which were severe RSV-associated diseases, reached a historical high rate of 2,182 cases per 1,0000,000 person-days in November 2022, corresponding to a related increase of 143% compared to expected peak rate (rate ratio: 2.43, 95% CI: 2.25-2.63). Among 228,940 children aged 0-5 years, the risk for first-time medically attended RSV during 10/2022-12/2022 was 6.40% for children with prior COVID-19 infection, higher than 4.30% for the matched children without COVID-19 (risk ratio or RR: 1.40, 95% CI: 1.27-1.55); and among 99,105 children aged 0-1 year, the overall risk was 7.90% for those with prior COVID-19 infection, higher than 5.64% for matched children without (RR: 1.40, 95% CI: 1.21-1.62). These data provide evidence that COVID-19 contributed to the 2022 surge of severe pediatric RSV cases.

Researching COVID to enhance recovery (RECOVER) pediatric study protocol: Rationale, objectives and design

Importance

The prevalence, pathophysiology, and long-term outcomes of COVID-19 (post-acute sequelae of SARS-CoV-2 [PASC] or "Long COVID") in children and young adults remain unknown. Studies must address the urgent need to define PASC, its mechanisms, and potential treatment targets in children and young adults.

Observations

We describe the protocol for the Pediatric Observational Cohort Study of the NIH's RE searching COV ID to E nhance R ecovery (RECOVER) Initiative. RECOVER-Pediatrics is an observational meta-cohort study of caregiver-child pairs (birth through 17 years) and young adults (18 through 25 years), recruited from more than 100 sites across the US. This report focuses on two of five cohorts that comprise RECOVER-Pediatrics: 1) a de novo RECOVER prospective cohort of children and young adults with and without previous or current infection; and 2) an extant cohort derived from the Adolescent Brain Cognitive Development (ABCD) study ( n =10,000). The de novo cohort incorporates three tiers of data collection: 1) remote baseline assessments (Tier 1, n=6000); 2) longitudinal follow-up for up to 4 years (Tier 2, n=6000); and 3) a subset of participants, primarily the most severely affected by PASC, who will undergo deep phenotyping to explore PASC pathophysiology (Tier 3, n=600). Youth enrolled in the ABCD study participate in Tier 1. The pediatric protocol was developed as a collaborative partnership of investigators, patients, researchers, clinicians, community partners, and federal partners, intentionally promoting inclusivity and diversity. The protocol is adaptive to facilitate responses to emerging science.

Conclusions and Relevance

RECOVER-Pediatrics seeks to characterize the clinical course, underlying mechanisms, and long-term effects of PASC from birth through 25 years old. RECOVER-Pediatrics is designed to elucidate the epidemiology, four-year clinical course, and sociodemographic correlates of pediatric PASC. The data and biosamples will allow examination of mechanistic hypotheses and biomarkers, thus providing insights into potential therapeutic interventions.

Clinical Trialsgov Identifier

Clinical Trial Registration: http://www.clinicaltrials.gov . Unique identifier: NCT05172011.

Risk of New Retinal Vascular Occlusion After mRNA COVID-19 Vaccination Within Aggregated Electronic Health Record Data

Importance

New-onset retinal vascular occlusion (RVO) occurring acutely after messenger RNA (mRNA) COVID-19 vaccination has been described in recent literature. Because RVO can cause vision loss or blindness, an epidemiologic investigation evaluating this potential association is of great importance to public health.

Objective

To investigate how often patients are diagnosed with new RVO acutely after the mRNA COVID-19 vaccine compared with influenza and tetanus, diphtheria, pertussis (Tdap) vaccines.

Design, Setting, and Participants

A retrospective population-based cohort design using the TriNetX Analytics platform, a federated, aggregated electronic health record (EHR) research network containing the deidentified EHR data of more than 103 million patients, was used to examine aggregate EHR data. Data were collected and analyzed on October 20, 2022. Data on patients within the TriNetX Analytics platform were searched for the presence of vaccination Common Procedural Technology codes, and instances of newly diagnosed RVO within 21 days of vaccination were recorded and reported. Propensity score matching based on demographic characteristics (age, sex, race and ethnicity) and comorbidities (diabetes, hypertension, and hyperlipidemia) was performed between vaccination groups for evaluation of relative risks (RRs).

Main Outcomes and Measures

The appearance of a new-encounter diagnosis of RVO within 21 days of the mRNA COVID-19 vaccination was the primary outcome. Historical comparison cohorts of patients receiving influenza and Tdap vaccinations allowed for evaluation of the RRs for RVO.

Results

Of 3 108 829 patients (mean [SD] age at vaccination, 50.7 [20.4] years; 56.4% women) who received the mRNA COVID-19 vaccine, 104 (0.003%; 95% CI, 0.003%-0.004%) patients had a new diagnosis of RVO within 21 days of vaccination. After propensity score matching, the RR for new RVO diagnosis after the first dose of COVID-19 vaccination was not significantly different from that after influenza (RR, 0.74; 95% CI, 0.54-1.01) or Tdap (RR, 0.78; 95% CI, 0.44-1.38) vaccinations, but was greater when compared with the second dose of the COVID-19 vaccination (RR, 2.25; 95% CI, 1.33-3.81).

Conclusions and Relevance

The findings of this study suggest that RVO diagnosed acutely after mRNA COVID-19 vaccination occurs extremely rarely at rates similar to those of 2 different historically used vaccinations, the influenza and Tdap vaccines. No evidence suggesting an association between the mRNA COVID-19 vaccination and newly diagnosed RVO was found.

Cardiovascular Outcomes After Tixagevimab and Cilgavimab use for Pre-Exposure Prophylaxis Against Coronavirus Disease 2019: A Population-Based Propensity-matched Cohort Study

Tixagevimab and cilgavimab treatment was associated with higher rates of cardiovascular events in a post hoc analysis of a phase 3 trial. In this large population-based propensity-matched study, we found no increased risk of cardiovascular events up to 90 days after tixagevimab and cilgavimab administration, including in patients with pre-existing cardiovascular disease.

Did the COVID-19 pandemic lead to increased pediatric musculoskeletal nonaccidental trauma? A cross-sectional study

Lockdowns due to COVID-19 increased known risk factors for nonaccidental trauma (NAT), including economic instability and parental stress. We sought to evaluate potential changes in the frequency and types of fractures associated with NAT during the COVID-19 pandemic. A retrospective cross-sectional study was conducted using de-identified data obtained from the IBM Watson Health Explorys Cohort Discovery database. Systematized Nomenclature of Medicine-Clinical Terms were used to query the database for victims of NAT in 2019 and 2020. Within this cohort of patients, we then identified those who were also diagnosed with a fracture within 21 days of the NAT event. Demographic data were compared between 2019 and 2020 where possible using chi-squared testing, and relative risks for various fracture diagnoses were calculated with 95% confidence intervals. There were 9500 records overall of pediatric NAT in 2019 compared to 9350 in 2020. Of those, in 2019 550 were associated with a diagnosis of fracture versus 570 in 2020. The relative risk of fracture due to NAT in 2020 when compared to 2019 was not significantly higher [relative risk, 1.05 (95% confidence interval, 0.94-1.17)]. The relative risk for each category of fracture diagnosis in 2020 was slightly higher, but not to a statistically significant degree. Despite increasing known risk factors, the frequency of NAT remained unchanged as the result of the COVID-19 pandemic. We also did not identify significant changes in the risk of fracture due to NAT, nor any changes in the associated types of fractures.

Ischemic stroke after COVID-19 bivalent vaccine administration in patients aged 65 years and older: analysis of nation-wide patient electronic health records in the United States

Importance

The Centers for Disease Control and Prevention (CDC) announced in January 2023 that they were investigating a potential connection between administration of the Pfizer novel coronavirus disease-2019 (COVID-19) bivalent vaccine booster and ischemic stroke (IS).

Objective

To explore the relationship between Pfizer bivalent booster administration and IS in older patients in the United States and compare it to other COVID-19 vaccines.

Design

A retrospective cohort study was conducted to compare hazard of IS among patients aged 65 years or over who received the Pfizer bivalent, Moderna bivalent, or Pfizer/Moderna monovalent COVID-19 booster vaccine 1-21 and 22-42 days after vaccination.

Setting

Patient data were collected from TriNetX, a cloud-based analytics platform that includes electronic health record data from over 90 million unique patients in the United States.

Participants

Patients in the United States aged 65 years or over at the time of administration of a Pfizer bivalent (n = 43,216), Moderna bivalent (n = 4,267), or Pfizer/Moderna monovalent (n = 100,583) booster were included for analysis. Cohorts were propensity-score matched by demographic factors and risk factors for IS and severe COVID-19.

Exposures

Pfizer bivalent, Moderna bivalent, or Pfizer/Moderna monovalent COVID-19 booster administration.

Main outcomes

The hazard ratio (HR) and 95% confidence interval (CI) for IS in the cohorts at 1-21 and 22-42 days after administration.

Results

After matching, the Pfizer bivalent cohort included 4,267 patients, with an average age of 73.7 years (44.43% male, 76.59% white). The Moderna bivalent cohort included 4,267 patients, with an average age of 74.0 years (44.08% male, 77.39% white). There was no significant difference in the hazard of IS encounters between the Pfizer bivalent versus Moderna bivalent cohorts at 1-21- or 22-42-days post-administration: HR = 0.59 (0.31, 1.11), 0.73 (0.33, 1.60). The hazard for IS was lower in the Pfizer bivalent cohort than in the Pfizer/Moderna monovalent cohort at both timepoints: HR = 0.24 (0.19, 0.29), 0.25 (0.20, 0.31).

Conclusions and relevance

Older adults administered the Pfizer bivalent booster had similar hazard for IS encounters compared to those administered the Moderna bivalent booster vaccine, but lower hazard than those administered the Pfizer/Moderna monovalent boosters.

Health outcomes associated with patterns of substance use disorders among patients with type 2 diabetes and hypertension: Electronic health record findings

AIMS

To identify substance use disorder (SUD) patterns and their association with T2DM health outcomes among patients with type 2 diabetes and hypertension.

METHODS

We used latent class analysis on electronic health records from the MetroHealth System (Cleveland, Ohio) to obtain the target SUD groups: i) only tobacco (TUD), ii) tobacco and alcohol (TAUD), and iii) tobacco, alcohol, and at least one more substance (PSUD). A matching program with Mahalanobis distance within propensity score calipers created the matched control groups: no SUD (NSUD) for TUD and TUD for the other two SUD groups. The numbers of participants for the target-control groups were 8009 (TUD), 1672 (TAUD), and 642 (PSUD).

RESULTS

TUD was significantly associated with T2DM complications. Compared to TUD, the TAUD group showed a significantly higher likelihood for all-cause mortality (adjusted odds ratio (aOR) = 1.46) but not for any of the T2DM complications. Compared to TUD, the PSUD group experienced a significantly higher risk for cerebrovascular accident (CVA) (aOR = 2.19), diabetic neuropathy (aOR = 1.76), myocardial infarction (MI) (aOR = 1.76), and all-cause mortality (aOR = 1.66).

CONCLUSIONS

The findings of increased risk associated with PSUDs may provide insights for better management of patients with T2DM and hypertension co-occurrence.

COVID-19 breakthrough infections and hospitalizations among vaccinated patients with dementia in the United States between December 2020 and August 2021

INTRODUCTION

There is lack of data on COVID-19 breakthrough infections in vaccinated patients with dementia in the United States.

METHODS

This is a retrospective cohort study of 262,847 vaccinated older adults (age 73.8 ± 6.81 years old) between December 2020 and August 2021.

RESULTS

Among the fully vaccinated patients with dementia, the overall risk of COVID-19 breakthrough infections ranged from 8.6% to 12.4%. Patients with dementia were at increased risk for breakthrough infections compared with patients without dementia, with the highest odds for patients with Lewy body dementia (LBD) (adjusted odds ratio or AOR: 3.06, 95% confidence interval or CI [1.45 to 6.66]), followed by vascular dementia (VD) (AOR: 1.99, 95% CI [1.42 to 2.80]), Alzheimer's disease (AD) (1.53, 95% CI [1.22 to 1.92]), and mild cognitive impairment (MCI) (AOR: 1.78, 95% CI [1.51 to 2.11]). The incidence rate of breakthrough infections among fully vaccinated patients with dementia increased since December 2020 and accelerated after May 2021. The overall risk for hospitalization after breakthrough infections in patients with dementia was 39.5% for AD, 46.2% for VD, and 30.4% for MCI.

DISCUSSION

These results highlight the need to continuously monitor breakthrough severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and outcomes in vaccinated patients with dementia.

Association of Recent SARS-CoV-2 Infection With New-Onset Alcohol Use Disorder, January 2020 Through January 2022

IMPORTANCE

The COVID-19 pandemic affects many diseases, including alcohol use disorders (AUDs). As the pandemic evolves, understanding the association of a new diagnosis of AUD with COVID-19 over time is required to mitigate negative consequences.

OBJECTIVE

To examine the association of COVID-19 infection with new diagnosis of AUD over time from January 2020 through January 2022.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study of electronic health records of US patients 12 years of age or older, new diagnoses of AUD were compared between patients with COVID-19 and patients with other respiratory infections who had never had COVID-19 by 3-month intervals from January 20, 2020, through January 27, 2022.

EXPOSURES

SARS-CoV-2 infection or non-SARS-CoV-2 respiratory infection.

MAIN OUTCOMES AND MEASURES

New diagnoses of AUD were compared in COVID-19 and propensity score-matched control cohorts by hazard ratios (HRs) and 95% CIs from either 14 days to 3 months or 3 to 6 months after the index event.

RESULTS

This study comprised 1 201 082 patients with COVID-19 (56.9% female patients; 65.7% White; mean [SD] age at index, 46.2 [18.9] years) and 1 620 100 patients with other respiratory infections who had never had COVID-19 (60.4% female patients; 71.1% White; mean [SD] age at index, 44.5 [20.6] years). There was a significantly increased risk of a new diagnosis of AUD in the 3 months after COVID-19 was contracted during the first 3 months of the pandemic (block 1) compared with control cohorts (HR, 2.53 [95% CI, 1.82-3.51]), but the risk decreased to nonsignificance in the next 3 time blocks (April 2020 to January 2021). The risk for AUD diagnosis increased after infection in January to April 2021 (HR, 1.30 [95% CI, 1.08-1.56]) and April to July 2021 (HR, 1.80 [95% CI, 1.47-2.21]). The result became nonsignificant again in blocks 7 and 8 (COVID-19 diagnosis between July 2021 and January 2022). A similar temporal pattern was seen for new diagnosis of AUD 3 to 6 months after infection with COVID-19 vs control index events.

CONCLUSIONS AND RELEVANCE

Elevated risk for AUD after COVID-19 infection compared with non-COVID-19 respiratory infections during some time frames may suggest an association of SARS-CoV-2 infection with the pandemic-associated increase in AUD. However, the lack of excess hazard in most time blocks makes it likely that the circumstances surrounding the pandemic and the fear and anxiety they created also were important factors associated with new diagnoses of AUD.

Association of COVID-19 with endocarditis in patients with cocaine or opioid use disorders in the US

The incidence of endocarditis in the US is increasing, driven in part by the rise in intravenous drug use, mostly opioids and stimulant drugs (cocaine and methamphetamine). Recent reports have documented that individuals with COVID-19 are at increased risk for cardiovascular diseases. However, it is unknown whether COVID-19 is associated with increased risk for endocarditis in patients with opioid or stimulant use disorders. This is a retrospective cohort study based on a nationwide database of electronic health records (EHRs) of 109 million patients in the US, including 736,502 patients with a diagnosis of opioid use disorder (OUD) and 379,623 patients with a diagnosis of cocaine use disorder (CocaineUD). Since Metamphetamine use disorder is not coded we could not analyze it. We show that the incidence rate of endocarditis among patients with OUD or CocaineUD significantly increased from 2011 to 2022 with acceleration during 2021-2022. COVID-19 was associated with increased risk of new diagnosis of endocarditis among patients with OUD (HR: 2.23, 95% CI: 1.92-2.60) and with CocaineUD (HR: 2.24, 95% CI: 1.79-2.80). Clinically diagnosed COVID-19 was associated with higher risk of endocarditis than lab-test confirmed COVID-19 without clinical diagnosis. Hospitalization within 2 weeks following COVID-19 infection was associated with increased risk of new diagnosis of endocarditis. The risk for endocarditis did not differ between patients with and without EHR-recorded vaccination. There were significant racial and ethnic differences in the risk for COVID-19 associated endocarditis, lower in blacks than in whites and lower in Hispanics than in non-Hispanics. Among patients with OUD or CocaineUD, the 180-day hospitalization risk following endocarditis was 67.5% in patients with COVID-19, compared to 58.7% in matched patients without COVID-19 (HR: 1.21, 95% CI: 1.07-1.35). The 180-day mortality risk following the new diagnosis of endocarditis was 9.2% in patients with COVID-19, compared to 8.0% in matched patients without COVID-19 (HR: 1.16, 95% CI: 0.83-1.61). This study shows that COVID-19 is associated with significantly increased risk for endocarditis in patients with opioid or cocaine use disorders. These results highlight the need for endocarditis screening and for linkage to infectious disease and addiction treatment in patients with opioid or cocaine use disorders who contracted COVID-19. Future studies are needed to understand how COVID-19 damages the heart and the vascular endothelium among people who misuse opioids or cocaine (presumably also methamphetamines).

Association of Aspirin Use with Reduced Risk of Developing Alzheimer's Disease in Elderly Ischemic Stroke Patients: A Retrospective Cohort Study

BACKGROUND

Currently there are no effective therapies to prevent or halt the development of Alzheimer's disease (AD). Multiple risk factors are involved in AD, including ischemic stroke (IS). Aspirin is often prescribed following IS to prevent blood clot formation. Observational studies have shown inconsistent findings with respect to the relationship between aspirin use and the risk of AD.

OBJECTIVE

To investigate the relationship between aspirin therapy after IS and the new diagnosis of AD in elderly patients.

METHODS

This retrospective cohort study leveraged a large database that contains over 90 million electronic health records to compare the hazard rates of AD after IS in elderly patients prescribed aspirin versus those not prescribed aspirin after propensity-score matching for relevant confounders.

RESULTS

At 1, 3, and 5 years after first IS, elderly patients prescribed aspirin were less likely to develop AD than those not prescribed aspirin: Hazard Ratio = 0.78 [0.65,0.94], 0.81 [0.70,0.94], and 0.76 [0.70,0.92].

CONCLUSION

Our findings suggest that aspirin use may prevent AD in patients with IS, a subpopulation at high risk of developing the disease.

Epidemiology of Eustachian tube dysfunction and related otologic diagnoses among children with achondroplasia

OBJECTIVE

To investigate the prevalence of diagnosed Eustachian tube dysfunction and related otologic diagnoses among children with achondroplasia as compared to a control population.

METHODS

The TriNetX Analytics Network, a federated health research network that aggregates the de-identified electronic health record data of over 78 million patients across the United States, was queried for patients 18 years old or younger with achondroplasia. Patients in this group with any occurrence of diagnosed Eustachian tube dysfunction or specified otologic diagnoses were recorded and reported.

RESULTS

Out of 2,195 patients 18 years old or younger with diagnosed achondroplasia, 379 (17.27%, 95% CI: 15.71-18.91) had a diagnosis of Eustachian tube dysfunction with an 8.65 (95% CI: 7.89-9.48) times higher risk than children without achondroplasia (n = 12,818,655). Children with achondroplasia also had higher risks for diagnosed otitis media (RR: 2.21), tympanic membrane retraction (RR: 7.29), middle ear cholesteatoma (RR: 6.35), cleft palate (RR: 12.24), conductive hearing loss (RR: 12.15), and tympanostomy tube placement (RR: 9.71). Each increased risk was maintained when cleft palate patients were removed from the achondroplasia group.

CONCLUSION

Children with achondroplasia are at a significantly higher risk for diagnosed Eustachian tube dysfunction and related middle ear diagnoses. Atypical craniofacial anatomy among children with achondroplasia may play a role in the dysfunction of the Eustachian tube and thus the observed epidemiology of otologic conditions. Children with achondroplasia should be monitored closely for middle ear conditions and the constellation of symptoms related to a dysfunctional Eustachian tube.

Disruption in seasonality, patient characteristics and disparities of respiratory syncytial virus infection among young children in the US during and before the COVID-19 pandemic: 2010-2022

Respiratory syncytial virus (RSV) infections and hospitalization have surged sharply among young children. Here we test how the seasonal patterns of RSV infections in 2022 compared with those from other COVID-19 pandemic and pre-pandemic years. For this purpose, we analyzed a nation-wide and real-time database of electronic health records of 56 million patients across 50 states in the US. The monthly incidence rate of first-time RSV infection in young children (<5 years of age) and very young children (<1 year of age) followed a seasonal pattern from 2010 to 2019 with increases during the autumn, peaking in winter, subsiding in spring and summer. This seasonal pattern was significantly disrupted during the COVID-19 pandemic. In 2020, the incidence rate of RSV infections was remarkably low throughout the year. In 2021, the RSV season expanded to 9 months starting in the early summer and peaking in October. In 2022, RSV infections started to rise in May and were significantly higher than in previous years reaching a historically highest incidence rate in November 2022. There were significant racial and ethnic disparities in the peak RSV infection rate during 2010-2021 and the disparities further exacerbated in 2022 with peak incidence rate in black and Hispanic children 2-3 times that in white children. Among RSV-infected children in 2022, 19.2% had prior documented COVID-19 infection, significantly higher than the 9.7% among uninfected children, suggesting that prior COVID-19 could be a risk factor for RSV infection or that there are common risk factors for both viral infections. Our study calls for continuous monitoring of RSV infection in young children alongside its clinical outcomes and for future work to assess potential COVID-19 related risk factors.

Phenotypic prevalence of obesity and metabolic syndrome among an underdiagnosed and underscreened population of over 50 million children and adults

Background: Metabolic syndrome is a phenotypic condition associated with a variety of genotypes. Studies of rare genotypes can be made more difficult by clinical underscreening of the population for the phenotypic traits that define metabolic syndrome to clinicians. Studies have demonstrated underdiagnosis of pediatric obesity, as well as reduced rates of pediatric screening for obesity related conditions, including conditions leading to a diagnosis of metabolic syndrome. If true, there may be a significant underdiagnosis of metabolic syndrome among the pediatric population compared to the adult population.

Methods: Using Epic’s Cosmos Data Network aggregated, de-identified patient data collected from healthcare organizations using the Epic electronic health record (EHR), we examined obesity and metabolic syndrome rates among adult and pediatric patients. We also examined screening rates for obesity related conditions and metabolic syndrome among adult and pediatric patients across the United States. We also sought to compare rates between subgroups within the population including age, sex, and race.

Results: In our population, 45% of adults and 27% of pediatric population were obese by age and gender specific BMI criteria. 38% of the obese adult population had an ICD-10 code associated with the diagnosis vs. 52% of the pediatric population. Of adults meeting obesity criteria, 36% had results for appropriate, guideline-based blood laboratory testing for insulin resistance, 40–42% for dyslipidemia, and 55% for hepatic steatosis. 36% of obese adult patients had none of the recommended blood laboratory testing. 31% of the adult population met diagnostic criteria for metabolic syndrome. Of pediatric patients meeting obesity criteria, 27% had results for appropriate blood laboratory testing for insulin resistance, 28% for dyslipidemia, and 33% for hepatic steatosis. 59% of obese pediatric patients had none of the recommended blood laboratory testing. 3% of the pediatric population met criteria for diagnosis of metabolic syndrome.

Discussion: This study represents one of the largest multicenter national cohorts assembled for studying metabolic syndrome (over 50 million patients) and demonstrates the power of emerging aggregated EHR tools for research. Although obesity is better diagnosed in pediatric patients than in adult patients, significantly lower screening rates for obesity related conditions occurred in pediatric patients compared to adults. Statistically significant, but clinically negligible differences in screening rates were found by race and gender. These results support smaller prior studies that suggest that obesity is under-diagnosed and obesity related conditions underscreened in pediatric and adult populations, and additionally suggests underdiagnosis of metabolic syndrome among United States pediatric and adult patients.

Association of SARS-CoV-2 Infection With New-Onset Type 1 Diabetes Among Pediatric Patients From 2020 to 2021

This cohort study assesses the association of COVID-19 with new-onset type 1 diabetes among pediatric patients.

Time to integrate oral health screening into medicine? A survey of primary care providers of older adults and an evidence-based rationale for integration

OBJECTIVE

Primary care providers were assessed regarding their training and interest to screen oral conditions in patients ≥55 years old.

BACKGROUND

Oral health (OH) is an essential component of overall health and can affect systemic health. Medical/dental integration in older adults is underdeveloped.

METHODS

A brief survey assessed primary care providers' self-reported skills, practices and barriers towards integrating OH screening into adult primary care. Data were collected using Survey Monkey® . Respondents were physicians and advanced practice providers (APPs) working at a large mid-western safety-net hospital. Descriptive statistics, T-tests and Chi-squared tests were reported.

RESULTS

Eighty-two of 202 participants (41%) completed the survey. Most respondents were female (75%). A majority were physicians (68%); the remainder APPs. All providers (100%) reported OH was important or extremely important to overall health. More physicians (93%) reported not being well-trained to address adult OH issues and perceived less medical-oral health integration in their practice (16%) compared to APPs (P < .05). Time was more of a barrier with APPs (74%), compared to physicians (51%), to integrate OH screening activities (P < .05). Most providers reported other barriers such as inadequate OH training and insurance coverage. Providers endorsed that OH should be assessed frequently (56%) including providing referrals to dentists (77%) and educating patients on oral-systemic issues (63%). More female than male providers endorsed dental referrals and educating patients (P < .05).

CONCLUSION

Primary care providers embraced greater medical/dental integration for older adults. Instituting OH activities appears to be supported. Future interventions that are feasible in primary care settings are examined.

Pediatric pelvic fractures: an epidemiological analysis of a population-based database

Despite a high prevalence in the pediatric trauma population, there remains a lack of large population-based epidemiological studies on pediatric pelvic fractures. Using a de-identified national clinical registry, we investigated the epidemiological features of pediatric pelvic fractures. We performed a retrospective analysis of data obtained from the IBM Watson Health Explorys Platform (Armonk, NY). From all children ages 0-14, two cohorts were created, children diagnosed with a traumatic injury and children diagnosed with a fracture of the pelvis. We then calculated the overall incidence of pelvic fractures, mortality rate, and identified common associated injuries, fracture locations, and complications. 2,690 pediatric pelvic fractures were identified yielding an incidence of 9.8/100,000 children per year with a mortality rate of 0.3%. Pelvic fractures were more common among Caucasians than in African Americans and Asians, and more common in males than females. The most common types of pelvic fracture were fractures of the ilium (42%), pubis (18%), sacrum (11%), ischium (10%), and acetabulum (8%). Most common associated injuries included injury of the lower extremity (43%), intracranial injury (16%), chest injury (13%), injury of the abdomen (9%), and urogenital injury (3%). Rates of common complications associated with malunion were low back pain (10%), acquired leg length discrepancy (1%), and acquired scoliosis (0.3%). The current incidence of pediatric pelvic fracture is 9.8/100,000 children per year with a mortality rate of 0.3%. Further study utilizing large data sets may help to better understand associated injuries, risks of poor outcomes, and optimize treatment strategies.

Five-year incidence of substance use and mental health diagnoses following exposure to opioids or opioids with benzodiazepines during an emergency department encounter for traumatic injury

BACKGROUND

Benzodiazepines and opioids are used alone or in conjunction in certain care settings, but each have the potential for misuse.

OBJECTIVE

This longitudinal observational study evaluated substance use and mental health outcomes associated with providing opioids with or without benzodiazepine to treat traumatic injury in the emergency department (ED) setting.

METHODS

We analyzed a limited dataset obtained through the IBM Watson Health Explorys. Matched cohorts were defined for: 1) patients treated with opioids during the ED encounter (ED-Opioid) vs. neither opioid or benzodiazepine treatment (No medication) (n = 5372); 2) patients treated with opioids and benzodiazepines during the ED encounter (ED-Opioid+Benzodiazepines) vs. No Medication (n = 2454); and 3) ED-Opioid+Benzodiazepines vs. ED-Opioid (n = 2454). Patients consisted of adults with an emergency department encounter in the MetroHealth System (Cleveland, Ohio) with a chief complaint of traumatic injury and medical records for five years following the encounter. Control patients for each cohort were matched to the exposure patients on demographics, body mass index, and residential zip code median income. Outcomes were five-year incidence rates for alcohol, substance use, depression, and anxiety-related diagnoses.

RESULTS

Our results indicate that, although receiving opioids during the ED visit predicted a relatively lower likelihood of subsequent substance use and mental health diagnoses, the brief co-use of benzodiazepines was strongly associated with poorer outcomes.

CONCLUSIONS

Even brief exposure to co-prescribed opioids and benzodiazepines during emergency traumatic injury care may be associated with negative substance use and mental health consequences in the years following the event.

COVID-19 rebound after Paxlovid treatment during Omicron BA.5 vs BA.2.12.1 subvariant predominance period

Paxlovid was authorized by FDA to treat mild-to-moderate COVID-19. In May 2022, the Centers for Disease Control and Prevention (CDC) issued a Health Alert Network Health Advisory on potential COVID-19 rebound after Paxlovid treatment. Since June 2022, Omicron BA.5 has become the dominant subvariant in the US, which is more resistant to neutralizing antibodies than the previous subvariant BA.2.12.1. Questions remain as to how COVID-19 rebound after Paxlovid treatment differs between the BA.5 and BA.2.12.1 subvariants. This is a retrospective cohort study of 15,913 patients who contracted COVID-19 between 5/8/2022-7/18/2022 and were prescribed Paxlovid within 5 days of their COVID-19 infection. The study population was divided into 2 cohorts: (1) BA.5 cohort (n=5,161) - contracted COVID-19 during 6/19/22-7/18/22 when BA.5 was the predominant subvariant2. (2) BA.2.12.1 cohort (n=10,752) - contracted COVID-19 during 5/8/22-6/18/22 when the BA.2.12.1 was the predominant subvariant. The risks of both COVID-19 rebound infections and symptoms 2-8 days after Paxlovid treatment were higher in the BA.5 cohort than in the propensity-score matched BA.2.12.1 cohort: rebound infections (Hazard Ratio or HR: 1.32, 95% CI: 1.06-1.66), rebound symptoms (HR: 1.32, 95% CI: 1.04-1.68). As SARS-CoV-2 evolves with successive subvariants more evasive to antibodies, continuous vigilant monitoring is necessary for COVID-19 rebounds after Paxlovid treatment and longer time duration of Paxlovid treatment warrants evaluation.