High-fidelity simulation versus case-based tutorial sessions for teaching pharmacology: Convergent mixed methods research investigating undergraduate medical students' performance and perception

INTRODUCTION

Medical educators strive to improve their curricula to enhance the student learning experience. The use of high-fidelity simulation within basic and clinical medical science subjects has been one of these initiatives. However, there is paucity of evidence on using simulation for teaching pharmacology, especially in the Middle East and North Africa region, and the effectiveness of this teaching modality, relative to more traditional ones, have not been sufficiently investigated. Accordingly, this study compares the effects of high-fidelity simulation, which is designed in alignment with adult and experiential learning theories, and traditional case-based tutorial sessions on the performance and perception of undergraduate Year 2 medical students in pharmacology in Dubai, United Arab Emirates.

METHODS

This study employed a convergent mixed methods approach. Forty-nine medical students were randomly assigned to one of two groups during the 16-week pharmacology course. Each group underwent one session delivered via high-fidelity simulation and another via a case-based tutorial. A short multiple-choice question quiz was administered twice (immediately upon completion of the respective sessions and 5 weeks afterwards) to assess knowledge retention. Furthermore, to explore the students' perceptions regarding the two modes of learning delivery (independently and in relation to each other), an evaluation survey was administered following the delivery of each session. Thereafter, the iterative joint display analysis was used to develop a holistic understanding of the effect of high-fidelity simulation in comparison to traditional case-based tutorial sessions on pharmacology learning in the context of the study.

RESULTS

There was no statistically significant difference in students' knowledge retention between high-fidelity simulation and case-based tutorial sessions. Yet, students expressed a greater preference for high-fidelity simulation, describing the corresponding sessions as more varied, better at reinforcing learning, and closer to reality. As such, the meta-inferences led to expansion of the overall understanding around students' satisfaction, to both confirmation and expansion of the systemic viewpoint around students' preferences, and lastly to refinement in relation to the perspective around retained knowledge.

CONCLUSION

High-fidelity simulation was found to be as effective as case-based tutorial sessions in terms of students' retention of knowledge. Nonetheless, students demonstrated a greater preference for high-fidelity simulation. The study advocates caution in adapting high-fidelity simulation, where careful appraisal can lend itself to identifying contexts where it is most effective.

Obstetric Complications and Birth Outcomes After Antenatal Coronavirus Disease 2019 (COVID-19) Vaccination

OBJECTIVE

To evaluate the association between antenatal messenger RNA (mRNA) coronavirus disease 2019 (COVID-19) vaccination and risk of adverse pregnancy outcomes.

METHODS

This was a retrospective cohort study of individuals with singleton pregnancies with live deliveries between June 1, 2021, and January 31, 2022, with data available from eight integrated health care systems in the Vaccine Safety Datalink. Vaccine exposure was defined as receipt of one or two mRNA COVID-19 vaccine doses (primary series) during pregnancy. Outcomes were preterm birth (PTB) before 37 weeks of gestation, small-for-gestational age (SGA) neonates, gestational diabetes mellitus (GDM), gestational hypertension, and preeclampsia-eclampsia-HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. Outcomes in individuals vaccinated were compared with those in propensity-matched individuals with unexposed pregnancies. Adjusted hazard ratios (aHRs) and 95% CIs were estimated for PTB and SGA using a time-dependent covariate Cox model, and adjusted relative risks (aRRs) were estimated for GDM, gestational hypertension, and preeclampsia-eclampsia-HELLP syndrome using Poisson regression with robust variance.

RESULTS

Among 55,591 individuals eligible for inclusion, 23,517 (42.3%) received one or two mRNA COVID-19 vaccine doses during pregnancy. Receipt of mRNA COVID-19 vaccination varied by maternal age, race, Hispanic ethnicity, and history of COVID-19. Compared with no vaccination, mRNA COVID-19 vaccination was associated with a decreased risk of PTB (rate: 6.4 [vaccinated] vs 7.7 [unvaccinated] per 100, aHR 0.89; 95% CI, 0.83-0.94). Messenger RNA COVID-19 vaccination was not associated with SGA (8.3 vs 7.4 per 100; aHR 1.06, 95% CI, 0.99-1.13), GDM (11.9 vs 10.6 per 100; aRR 1.00, 95% CI, 0.90-1.10), gestational hypertension (10.8 vs 9.9 per 100; aRR 1.08, 95% CI, 0.96-1.22), or preeclampsia-eclampsia-HELLP syndrome (8.9 vs 8.4 per 100; aRR 1.10, 95% CI, 0.97-1.24).

CONCLUSION

Receipt of an mRNA COVID-19 vaccine during pregnancy was not associated with an increased risk of adverse pregnancy outcomes; this information will be helpful for patients and clinicians when considering COVID-19 vaccination in pregnancy.

Professionalism-training in undergraduate medical education in a multi-cultural, multi-ethnic setting in the Gulf Region: an exploration of reflective essays

BACKGROUND

Despite the established need to prioritize professionalism-training in developing future physicians, very few medical programs in the Gulf Region embed in their curricula discrete contextualized courses aimed at developing the corresponding competencies, while fostering self-directed learning. This study aims at exploring the perception of undergraduate medical students in a multi-cultural, multi-ethnic setting regarding their understanding of, and personal experience with professionalism through their engagement with the content of an innovative curriculum-based professionalism course, offered at a Medical School in Dubai, United Arab Emirates.

METHODS

The study used a qualitative phenomenological research design. Out of 33 students, 29 students had submitted reflective essays. The content of these essays was inductively analyzed following a six-step framework for conducting thematic analysis. The framework's steps include familiarizing oneself with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report.

FINDINGS

The inductive qualitative analysis generated the Professionalism Learning Journey model. This conceptual model includes four interconnected themes: Awareness, Acknowledgement, Realization, and Application. The generated model depicts the trajectory that the learners appear to experience while they are engaging with the content of the course.

CONCLUSION

Integrating a professionalism-training course into an undergraduate medical curriculum is likely to be positively appraised by the learners. It raises their awareness, enables them to value the subject matter and the sophistication of its application, and empowers them to put into practice the taught principles, on an individual basis and collectively. This is especially true when the course is entrenched in constructivism experiential learning theory and designed to foster self-directed learning. The introduced conceptual model, in conjunction with the innovative professionalism-training course curriculum, can serve as a template for other competencies and other schools.

Clinical learning environments across two different healthcare settings using the undergraduate clinical education environment measure

BACKGROUND

The clinical placements of our medical students are almost equally distributed across private and public sectors. This study aims to assess medical students' perceptions of their Clinical learning Environment (CLE) across these two different healthcare settings, using the Undergraduate Clinical Education Environment Measure (UCEEM).

METHODS

76 undergraduate medical students (Year 5 and 6), were invited to participate. Data were collected using an online UCEEM with additional questions related to demographics and case load exposure. The UCEEM consists of two overarching domains of experiential learning and social participation, with four subdomains of learning opportunities, preparedness, workplace interaction, and inclusion.

RESULTS

38 questionnaires were received. Of 225 responses to the individual UCEEM items, 51 (22.6%) scored a mean of ≥ 4 (range 4-4.5, representing strong areas), 31 (13.7%) scored a mean of ≤ 3 (range 2.1-3, needing attention) and 143 (63.6%) scored a mean of 3.1-3.9 (areas that could be improved). The majority (63%) of the case load exposure responses scored a mean of ≥ 4 (range 4-4.5). Compared to the private sittings, there is a significant reduction in total UCEEM (p = 0.008), preparedness for student entry (p = 0.003), and overarching dimension of social participation (p = 0.000) scores for the public sector. Similarly, both workplace interaction patterns and student inclusion and equal treatment scored significantly lower for the public sector (p = 0.000 and p = 0.011 respectively). Two out of three case load exposure items scored significantly higher for the public sector (p = 0.000).

DISCUSSION

The students' CLE perceptions were generally positive. The lower UCEEM ratings in the public sector items were related to student entry preparedness, workplace interactions, student inclusiveness and workforce equity of treatment. In contrast the students were exposed to more variety and larger number of patients in the public sector. These differences indicated some significantly different learning environments between the two sectors.

Using team-based learning to optimize undergraduate family medicine clerkship training: mixed methods study

BACKGROUND

Team-Based Learning (TBL) is an established educational strategy which has become increasingly popular in the training of healthcare professionals. TBL is highly suitable for teaching Family Medicine (FM) especially that teamwork and collaborative care, in this medical discipline, are at the core of safe and effective practice. Despite the established suitability of TBL for teaching FM, there are no empirical studies that capture the students' perception of a TBL in FM undergraduate learning experience in the Middle East and North Africa region (MENA).

OBJECTIVE

The overall objective of this study was to investigate the perception of students regarding a TBL in FM intervention (in Dubai, United Arab Emirates), that was designed and implemented in alignment with a constructivist learning theory.

METHODS

A convergent mixed methods study design was utilized to develop a thorough understanding of the students' perceptions. Qualitative and quantitative data were concurrently collected and independently analyzed. The output of thematic analysis was systematically merged with the quantitative descriptive and inferential findings using the iterative joint display process.

RESULTS

The qualitative findings shed light on the students' perception of TBL in FM, and the interplay between team cohesion and engagement with the course. As for the quantitative findings, they showed that the percentage of the total average of the Satisfaction with TBL in FM score was 88.80%. As for change in impression of FM discipline, the percentage of the total average was 83.10%. The perception of team cohesion, with a mean of agreement of 8.62(1.34), seemed to be significantly associated with the students' perception of the team test phase component, only (P < 0.05). As for the perception of the level of engagement with the course, with a mean of agreement of 9.29(0.84), it turned out to be significantly associated with the change in impression of FM discipline (P < 0.05). Lastly, the joint display analysis showed how the quantitative and qualitative findings built upon each other, revealing how best to leverage TBL in FM trainings.

CONCLUSION

The current study showed that TBL embedded in a FM clinical clerkship was well-received by students. It is worth leveraging the lessons learned from the first-hand experience reported upon in the current study to optimize the utilization of TBL in FM.

Tdap vaccination during pregnancy and risk of chorioamnionitis and related infant outcomes

INTRODUCTION

An increased risk of chorioamnionitis in people receiving tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine during pregnancy has been reported. The importance of this association is unclear as additional study has not demonstrated increased adverse infant outcomes associated with Tdap vaccination in pregnancy.

METHODS

We conducted a retrospective observational cohort study of pregnant people ages 15-49 years with singleton pregnancies ending in live birth who were members of 8 Vaccine Safety Datalink (VSD) sites during October 2016-September 2018. We used a time-dependent covariate Cox model with stabilized inverse probability weights applied to evaluate associations between Tdap vaccination during pregnancy and chorioamnionitis and preterm birth outcomes. We used Poisson regression with robust variance with stabilized inverse probability weights applied to evaluate the association of Tdap vaccination with adverse infant outcomes. We performed medical record reviews on a random sample of patients with ICD-10-CM-diagnosed chorioamnionitis to determine positive predictive values (PPV) of coded chorioamnionitisfor "probable clinical chorioamnionitis," "possible clinical chorioamnionitis," or "histologic chorioamnionitis."

RESULTS

We included 118,211 pregnant people; 103,258 (87%) received Tdap vaccine during pregnancy; 8098 (7%) were diagnosed with chorioamnionitis. The adjusted hazard ratio for chorioamnionitis in the Tdap vaccine-exposed group compared to unexposed was 0.96 (95% CI 0.90-1.03). There was no association between Tdap vaccine and preterm birth or adverse infant outcomes associated with chorioamnionitis. Chart reviews were performed for 528 pregnant people with chorioamnionitis. The PPV for clinical (probable or possible clinical chorioamnionitis) was 48% and 59% for histologic chorioamnionitis. The PPV for the combined outcome of clinical or histologic chorioamnionitis was 81%.

CONCLUSIONS AND RELEVANCE

Tdap vaccine exposure during pregnancy was not associated with chorioamnionitis, preterm birth, or adverse infant outcomes. ICD-10 codes for chorioamnionitis lack specificity for clinical chorioamnionitis and should be a recognized limitation when interpreting results.

Bivalent and Monovalent SARS-CoV-2 Variant Vaccine Boosters Improve coverage of the known Antigenic Landscape: Results of the COVID-19 Variant Immunologic Landscape (COVAIL) Trial

Vaccine protection against COVID-19 wanes over time and has been impacted by the emergence of new variants with increasing escape of neutralization. The COVID-19 Variant Immunologic Landscape (COVAIL) randomized clinical trial (clinicaltrials.gov NCT05289037) compares the breadth, magnitude and durability of antibody responses induced by a second COVID-19 vaccine boost with mRNA (Moderna mRNA-1273 and Pfizer-BioNTech BNT162b2), or adjuvanted recombinant protein (Sanofi CoV2 preS DTM-AS03) monovalent or bivalent vaccine candidates targeting ancestral and variant SARS-CoV-2 spike antigens (Beta, Delta and Omicron BA.1). We found that boosting with a variant strain is not associated with loss in neutralization against the ancestral strain. However, while variant vaccines compared to the prototype/wildtype vaccines demonstrated higher neutralizing activity against Omicron BA.1 and BA.4/5 subvariants for up to 3 months after vaccination, neutralizing activity was lower for more recent Omicron subvariants. Our study, incorporating both antigenic distances and serologic landscapes, can provide a framework for objectively guiding decisions for future vaccine updates.

Plasmodium 18S Ribosomal RNA Biomarker Clearance After Food and Drug Administration-Approved Antimalarial Treatment in Controlled Human Malaria Infection Trials

Background

Sensitive molecular assays, such as quantitative reverse-transcription polymerase chain reaction (qRT-PCR) of Plasmodium 18S ribosomal RNA (rRNA), are increasingly the primary method of detecting infections in controlled human malaria infection (CHMI) trials. However, thick blood smears (TBSs) remain the main method for confirming clearance of parasites after curative treatment, in part owing to uncertainty regarding biomarker clearance rates.

Methods

For this analysis, 18S rRNA qRT-PCR data were compiled from 127 Plasmodium falciparum-infected participants treated with chloroquine or atovaquone-proguanil in 6 CHMI studies conducted in Seattle, Washington, over the past decade. A survival analysis approach was used to compare biomarker and TBS clearance times among studies. The effect of the parasite density at which treatment was initiated on clearance time was estimated using linear regression.

Results

The median time to biomarker clearance was 3 days (interquartile range, 3-5 days), while the median time to TBS clearance was 1 day (1-2 days). Time to biomarker clearance increased with the parasite density at which treatment was initiated. Parasite density did not have a significant effect on TBS clearance.

Conclusions

The Plasmodium 18S rRNA biomarker clears quickly and can be relied on to confirm the adequacy of Food and Drug Administration-approved treatments in CHMI studies at nonendemic sites.

Safety and efficacy of tenecteplase in patients with wake-up stroke assessed by non-contrast CT (TWIST): a multicentre, open-label, randomised controlled trial

BACKGROUND

Current evidence supports the use of intravenous thrombolysis with alteplase in patients with wake-up stroke selected with MRI or perfusion imaging and is recommended in clinical guidelines. However, access to advanced imaging techniques is often scarce. We aimed to determine whether thrombolytic treatment with intravenous tenecteplase given within 4·5 h of awakening improves functional outcome in patients with ischaemic wake-up stroke selected using non-contrast CT.

METHODS

TWIST was an investigator-initiated, multicentre, open-label, randomised controlled trial with blinded endpoint assessment, conducted at 77 hospitals in ten countries. We included patients aged 18 years or older with acute ischaemic stroke symptoms upon awakening, limb weakness, a National Institutes of Health Stroke Scale (NIHSS) score of 3 or higher or aphasia, a non-contrast CT examination of the head, and the ability to receive tenecteplase within 4·5 h of awakening. Patients were randomly assigned (1:1) to either a single intravenous bolus of tenecteplase 0·25 mg per kg of bodyweight (maximum 25 mg) or control (no thrombolysis) using a central, web-based, computer-generated randomisation schedule. Trained research personnel, who conducted telephone interviews at 90 days (follow-up), were masked to treatment allocation. Clinical assessments were performed on day 1 (at baseline) and day 7 of hospital admission (or at discharge, whichever occurred first). The primary outcome was functional outcome assessed by the modified Rankin Scale (mRS) at 90 days and analysed using ordinal logistic regression in the intention-to-treat population. This trial is registered with EudraCT (2014-000096-80), ClinicalTrials.gov (NCT03181360), and ISRCTN (10601890).

FINDINGS

From June 12, 2017, to Sept 30, 2021, 578 of the required 600 patients were enrolled (288 randomly assigned to the tenecteplase group and 290 to the control group [intention-to-treat population]). The median age of participants was 73·7 years (IQR 65·9-81·1). 332 (57%) of 578 participants were male and 246 (43%) were female. Treatment with tenecteplase was not associated with better functional outcome, according to mRS score at 90 days (adjusted OR 1·18, 95% CI 0·88-1·58; p=0·27). Mortality at 90 days did not significantly differ between treatment groups (28 [10%] patients in the tenecteplase group and 23 [8%] in the control group; adjusted HR 1·29, 95% CI 0·74-2·26; p=0·37). Symptomatic intracranial haemorrhage occurred in six (2%) patients in the tenecteplase group versus three (1%) in the control group (adjusted OR 2·17, 95% CI 0·53-8·87; p=0·28), whereas any intracranial haemorrhage occurred in 33 (11%) versus 30 (10%) patients (adjusted OR 1·14, 0·67-1·94; p=0·64).

INTERPRETATION

In patients with wake-up stroke selected with non-contrast CT, treatment with tenecteplase was not associated with better functional outcome at 90 days. The number of symptomatic haemorrhages and any intracranial haemorrhages in both treatment groups was similar to findings from previous trials of wake-up stroke patients selected using advanced imaging. Current evidence does not support treatment with tenecteplase in patients selected with non-contrast CT.

FUNDING

Norwegian Clinical Research Therapy in the Specialist Health Services Programme, the Swiss Heart Foundation, the British Heart Foundation, and the Norwegian National Association for Public Health.

Efficacy and safety of a single dose of casirivimab and imdevimab for the prevention of COVID-19 over an 8-month period: a randomised, double-blind, placebo-controlled trial

BACKGROUND

There is an unmet need for COVID-19 prevention in patient populations who have not mounted or are not expected to mount an adequate immune response to complete COVID-19 vaccination. We previously reported that a single subcutaneous 1200 mg dose of the monoclonal antibody combination casirivimab and imdevimab (CAS + IMD) prevented symptomatic SARS-CoV-2 infections by 81·4% in generally healthy household contacts of SARS-CoV-2-infected individuals over a 1-month efficacy assessment period. Here we present additional results, including the 7-month follow-up period (months 2-8), providing additional insights about the potential for efficacy in pre-exposure prophylaxis settings.

METHODS

This was a randomised, double-blind, placebo-controlled trial done in the USA, Romania, and Moldova in 2020-2021, before the emergence of omicron (B.1.1.529) and omicron-lineage variants. Uninfected and unvaccinated household contacts of infected individuals, judged by the investigator to be in good health, were randomly assigned (1:1) to receive 1200 mg CAS + IMD or placebo by subcutaneous injection according to a central randomisation scheme provided by an interactive web response system; randomisation was stratified per site by the test results of a local diagnostic assay for SARS-CoV-2 and age group at baseline. COVID-19 vaccines were prohibited before randomisation, but participants were allowed to receive COVID-19 vaccination during the follow-up period. Participants who developed COVID-19 symptoms during the follow-up period underwent RT-PCR testing. Prespecified endpoints included the proportion of previously uninfected and baseline-seronegative participants (seronegative-modified full analysis set) who had RT-PCR-confirmed COVID-19 in the follow-up period (post-hoc for the timepoints of months 2-5 and 6-8 only) and underwent seroconversion (ie, became seropositive, considered a proxy for any SARS-CoV-2 infections [symptomatic and asymptomatic]; prespecified up to day 57, post-hoc for all timepoints thereafter). We also assessed the incidence of treatment-emergent adverse events. This study is registered with ClinicalTrials.gov, NCT04452318.

FINDINGS

From July 13, 2020, to Oct 4, 2021, 2317 participants who were RT-PCR-negative for SARS-CoV-2 were randomly assigned, of whom 1683 (841 assigned to CAS + IMD and 842 assigned to placebo) were seronegative at baseline. During the entirety of the 8-month study, CAS + IMD reduced the risk of COVID-19 by 81·2% (nominal p<0·0001) versus placebo (prespecified analysis). During the 7-month follow-up period, protection was greatest during months 2-5, with a 100% relative risk reduction in COVID-19 (nominal p<0·0001; post-hoc analysis). Efficacy waned during months 6-8 (post-hoc analysis). Seroconversion occurred in 38 (4·5%) of 841 participants in the CAS + IMD group and in 181 (21·5%) of 842 in the placebo group during the 8-month study (79·0% relative risk reduction vs placebo; nominal p<0·0001). Six participants in the placebo group were hospitalised due to COVID-19 versus none who received CAS + IMD. Serious treatment-emergent adverse events (including COVID-19) were reported in 24 (1·7%) of 1439 participants receiving CAS + IMD and in 23 (1·6%) of 1428 receiving placebo. Five deaths were reported, none of which were due to COVID-19 or related to the study drugs.

INTERPRETATION

CAS + IMD is not authorised in any US region as of Jan 24, 2022, because data show that CAS + IMD is not active against omicron-lineage variants. In this study, done before the emergence of omicron-lineage variants, a single subcutaneous 1200 mg dose of CAS + IMD protected against COVID-19 for up to 5 months of community exposure to susceptible strains of SARS-CoV-2 in the pre-exposure prophylaxis setting, in addition to the post-exposure prophylaxis setting that was previously shown.

FUNDING

Regeneron Pharmaceuticals, F Hoffmann-La Roche, US National Institute of Allergy and Infectious Diseases, US National Institutes of Health.

Clinical features and treatment outcomes of pulmonary Mycobacterium avium-intracellulare complex with and without co-infections

Coinfections are more common in patients with cystic fibrosis and bronchiectasis. Infiltrates on imaging studies are seen more commonly in patients with coinfections, but coinfections did not affect treatment outcomes of pulmonary Mycobacterium avium complex.

POS1147 CHALLENGES IN CONDUCTING PRAGMATIC CARE STRATEGY STUDIES IN OSTEOPOROSIS: PATIENT PERCEPTIONS

Background

Large pragmatic osteoporosis studies to improve outcomes are needed. Direct-to-patient studies have highest generalizability but achieving sufficient sample size is difficult; recruitment challenges represent an important consideration given limited participant eligibility and interest. The Fracture Liaison Service (FLS), a team approach to post-fracture care, is a secondary fracture prevention method that has significantly improved outcomes internationally.

Objectives

Our goal was to evaluate the interest, barriers, and lessons learned in recruiting participants for a future trial assessing remote FLS approaches for post-fracture care.

Methods

We used ICD10 fracture codes to identify patients > 50 years of age with a documented hip/pelvis, spine, humerus, or wrist fracture in the previous 1 year. We excluded patients with i) prescriptions for osteoporosis medications (e.g., bisphosphonates, parathyroid hormone analogs, denosumab, romosozumab, raloxifene) in the prior 1 year; ii) an ICD10 code for end-stage renal disease, non-osteoporotic metabolic bone disease, malignant neoplasm, or motor vehicle accident. In December 2021, research assistants reviewed electronic health records (EHR) of potentially eligible patients for evidence of additional serious illness limiting life expectancy to < 1 year or non-ambulatory status prior to fracture. Research assistants called preliminary eligible patients that met inclusion and exclusion criteria and asked them to complete a survey by phone. Interest in a FLS future clinical trial was evaluated using a Likert scale (1=“Definitely would not volunteer”, to 5=“Definitely would volunteer”). We used descriptive statistics to analyze baseline demographic, clinical characteristics, and interest. This pilot was approved by the UAB Institutional Review Board (IRB-300008310-005).

Results

We identified 1,577 patients > 50 years of age with a fracture. After applying exclusion criteria, we identified 869 preliminary eligible patients. Over 3 weeks, we screened the medical records of a random sample of half of the preliminary eligible patient cohort (n=414), of whom we contacted 271 patients determined potentially eligible, and successfully reached 141 (52% of those contacted) by phone. A total of 108 (77% of those reached) persons, mean (SD) age 69.5 (11.5) years, 40% men, 21% Black or non-white Hispanics completed the survey. Among those contacted, 68 (63%, interest rate) said they would be very or highly interested in participating in a future clinical trial evaluating FLS approaches. Among the 40 (37%) people who said they were not sure, unlikely or very unlikely to volunteer the most common reasons cited were “I don’t want to participate in a study” (33%); “I don’t feel well enough to participate” (10%); “I don’t understand what the study is for” (3%). From this pilot, we calculated a refined eligibility/interest rate of 9.1% among those patients preliminarily identified as eligible using administrative data alone.

Conclusion

Based on our pilot, we estimate that approximately 9% of eligible patients with fractures will be interested in enrolling in a future comparative effectiveness study to prevent recurrent fragility fractures. We identified several potential modifiable barriers to clinical trial recruitment. Patient perceptions collected from this pilot will inform enrollment strategies, which can be incorporated early when planning direct-to-patient pragmatic osteoporosis studies to achieve recruitment goals.

Disclosure of Interests

Lesley Jackson: None declared, Ellen McNeeley: None declared, Norma C. Techarukpong: None declared, Faith Mugeta: None declared, Kiara Aaron: None declared, Amy Mudano: None declared, Jeanne Merchant: None declared, Kellie Warren: None declared, Jeff Foster: None declared, Kenneth Saag Grant/research support from: Amgen, Horizon, LG Chem, Radius, SOBI, Maria Danila Grant/research support from: Pfizer, Horizon

POS1171 TRIPLE THE RATE OF EMERGENCY ROOM VISITS AND HOSPITALIZATIONS FOR GOUT AMONG US BLACKS VS WHITES – 2019 NATIONWIDE ANALYSIS

Background

Gout is a highly prevalent inflammatory arthritis with increasing global disease burden in recent years.1,2 Gout prevalence has been reported to be higher among Blacks compared to Whites,3 and that they are less likely to receive allopurinol in outpatient care.4 The potential nationwide impact of these racial disparities on emergency department (ED) visits and hospitalizations is unknown.

Objectives

To examine the contemporary racial disparities in ED visits and hospitalizations with a primary discharge diagnosis of gout in the US (2019).

Methods

We compared ED visits and hospitalizations between Blacks and Whites in the latest data (2019) from the US National Emergency Department Sample (NEDS) and National Inpatient Sample (NIS). We focused on encounters for which the primary diagnosis was gout based on ICD codes (M1A.xx, M10.xx). We calculated annual population rates of ED visits and hospitalizations for gout (per 100,000 US adults) using the 2019 US census adult population (>18 years) according to race.

Results

There were a total of 160,759 ED visits and 9,560 hospitalizations among White and Blacks with a gout diagnosis in the US in 2019. The mean age (58.2 years vs. 56.5 years) and male proportion (78.0% vs. 74.8%) tended to be higher among Whites, while more Blacks tended to live in the South (40.7% vs. 66.5%) and reported a median household income of < $50,000 (30.7% vs. 57.1%). Compared to Whites, Blacks had 2.7- and 3.2-fold higher rates of gout ED visits and hospitalizations, respectively, after adjusting for age, sex, payer, region, and household income (Table 1 & Figure 1). Black women, in particular, had 3.4- and 4.0-fold higher rates of ED visits and hospitalizations compared to White women, while the corresponding rate ratios for men were 2.5 and 2.8, respectively. The mean costs per gout ED visit were similar for Blacks compared to Whites (adjusted difference, -$7.6 [95% CI, -25.4 to 1.0]), while hospitalizations were more costly (adjusted difference, $1,055.3 [95% CI, 553.1 to 1557.5]). The duration of ED visits and hospitalizations was also higher among Blacks than Whites (adjusted difference of 0.41 days [95% CI, 0.19 to 0.63] and 0.59 days [95% CI, 0.25 to 0.94], respectively).

Table 1.

Racial Disparities in Emergency Department Visits and Hospitalizations with Primary Diagnosis of Gout in 2019

Emergency Department VisitsHospitalizationsRaceWhiteBlackWhiteBlackAll6801196524521330198510434519150Visits, N888107194962003360Rate per 100,000130.6293.431.274.4Rate Ratio (95% CI)*1.0 (ref)2.81 (2.63, 3.00)1.0 (ref)3.08 (2.79, 3.40)Rate Ratio (95% CI)**1.0 (ref)2.66 (2.50, 2.82)1.0 (ref)3.17 (2.86, 3.50)Women3785136914363031110390932647105Visits, N195671816317701145Rate per 100,00051.7126.516.043.3Rate Ratio (95% CI)*1.0 (ref)3.68 (3.39, 3.99)1.0 (ref)4.01 (3.40, 4.73)Rate Ratio (95% CI)**1.0 (ref)3.36 (3.11, 3.62)1.0 (ref)4.02 (3.39, 4.78)Men301561011015657388098151871620Visits, N692285378344302215Rate per 100,000229.6529.550.3118.3Rate Ratio (95% CI)*1.0 (ref)2.59 (2.42, 2.78)1.0 (ref)2.66 (2.36, 3.00)Rate Ratio (95% CI)**1.0 (ref)2.47 (2.32, 2.64)1.0 (ref)2.77 (2.45, 3.14)

*Adjusted for age and sex for all, adjusted for age for sex-specific rate ratios

**Adjusted for age, sex, payment, region, and household income

Conclusion

These latest national data indicate that ED visits and hospitalization due to gout are both 3 times higher among Blacks than Whites; this disparity was particularly prominent among women with gout. Higher risk of developing gout3 and suboptimal care4 both translate to these avoidable costly healthcare utilizations, calling for improved primary prevention and gout care.

References

[1]Safiri et al., PMID 32755051

[2]Xia et al., PMID 31624843

[3]Chen-Xu et al., PMID 30618180

[4]Krishnan et al., PMID 18260174

Disclosure of Interests

Chio Yokose: None declared, Natalie McCormick: None declared, Na Lu: None declared, Amit Joshi: None declared, Lesley Jackson: None declared, Minna Kohler Speakers bureau: Lilly, Consultant of: Mymee, Novartis, Grant/research support from: Setpoint Medical, Janeth Yinh: None declared, Yuqing Zhang: None declared, Kenneth Saag Consultant of: Arthrosi, Atom Bioscience, Horizon Therapeutics, LG Pharma, Mallinkrodt, SOBI, Takeda, Grant/research support from: Horizon Therapeutics, SOBI, Shanton, Hyon Choi Consultant of: Ironwood, Selecta, Horizon, Takeda, Kowa, and Vaxart, Grant/research support from: Ironwood and Horizon

Safety and Immunogenicity of a Third Dose of SARS-CoV-2 mRNA Vaccine - An Interim Analysis

Waning immunity after two SARS-CoV-2 mRNA vaccinations and the emergence of variants precipitated the need for a third dose of vaccine. We evaluated early safety and immunogenicity after a third mRNA vaccination in adults who received the mRNA-1273 primary series in the Phase 1 trial approximately 9 to 10 months earlier. The booster vaccine formulations included 100 mcg of mRNA-1273, 50 mcg of mRNA-1273.351 that encodes Beta variant spike protein, and bivalent vaccine of 25 mcg each of mRNA-1273 and mRNA-1273.351. A third dose of mRNA vaccine appeared safe with acceptable reactogenicity. Vaccination induced rapid increases in binding and neutralizing antibody titers to D614G, Beta, and Delta variants that were similar or greater than peak responses after the second dose. Spike-specific CD4+ and CD8+ T cells increased to similar levels as after the second dose. A third mRNA vaccination was well tolerated and generated robust humoral and T cell responses. ClinicalTrials.gov numbers NCT04283461 (mRNA-1273 Phase 1) and NCT04785144 (mRNA-1273.351 Phase 1).

Durability of mRNA-1273 vaccine-induced antibodies against SARS-CoV-2 variants

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mutations may diminish vaccine-induced protective immune responses, particularly as antibody titers wane over time. Here, we assess the effect of SARS-CoV-2 variants B.1.1.7 (Alpha), B.1.351 (Beta), P.1 (Gamma), B.1.429 (Epsilon), B.1.526 (Iota), and B.1.617.2 (Delta) on binding, neutralizing, and angiotensin-converting enzyme 2 (ACE2)–competing antibodies elicited by the messenger RNA (mRNA) vaccine mRNA-1273 over 7 months. Cross-reactive neutralizing responses were rare after a single dose. At the peak of response to the second vaccine dose, all individuals had responses to all variants. Binding and functional antibodies against variants persisted in most subjects, albeit at low levels, for 6 months after the primary series of the mRNA-1273 vaccine. Across all assays, B.1.351 had the lowest antibody recognition. These data complement ongoing studies to inform the potential need for additional boost vaccinations.

COVID-19 Vaccination Coverage Among Pregnant Women During Pregnancy - Eight Integrated Health Care Organizations, United States, December 14, 2020-May 8, 2021

COVID-19 vaccines are critical for ending the COVID-19 pandemic; however, current data about vaccination coverage and safety in pregnant women are limited. Pregnant women are at increased risk for severe illness and death from COVID-19 compared with nonpregnant women of reproductive age, and are at risk for adverse pregnancy outcomes, such as preterm birth (1-4). Pregnant women are eligible for and can receive any of the three COVID-19 vaccines available in the United States via Emergency Use Authorization.* Data from Vaccine Safety Datalink (VSD), a collaboration between CDC and multiple integrated health systems, were analyzed to assess receipt of ≥1 dose (first or second dose of the Pfizer-BioNTech or Moderna vaccines or a single dose of the Janssen [Johnson & Johnson] vaccine) of any COVID-19 vaccine during pregnancy, receipt of first dose of a 2-dose COVID-19 vaccine (initiation), or completion of a 1- or 2-dose COVID-19 vaccination series. During December 14, 2020-May 8, 2021, a total of 135,968 pregnant women were identified, 22,197 (16.3%) of whom had received ≥1 dose of a vaccine during pregnancy. Among these 135,968 women, 7,154 (5.3%) had initiated and 15,043 (11.1%) had completed vaccination during pregnancy. Receipt of ≥1 dose of COVID-19 vaccine during pregnancy was highest among women aged 35-49 years (22.7%) and lowest among those aged 18-24 years (5.5%), and higher among non-Hispanic Asian (Asian) (24.7%) and non-Hispanic White (White) women (19.7%) than among Hispanic (11.9%) and non-Hispanic Black (Black) women (6.0%). Vaccination coverage increased among all racial and ethnic groups over the analytic period, likely because of increased eligibility for vaccination^† and increased availability of vaccine over time. These findings indicate the need for improved outreach to and engagement with pregnant women, especially those from racial and ethnic minority groups who might be at higher risk for severe health outcomes because of COVID-19 (4). In addition, providing accurate and timely information about COVID-19 vaccination to health care providers, pregnant women, and women of reproductive age can improve vaccine confidence and coverage by ensuring optimal shared clinical decision-making.

Durability of mRNA-1273-induced antibodies against SARS-CoV-2 variants

SARS-CoV-2 mutations may diminish vaccine-induced protective immune responses, and the durability of such responses has not been previously reported. Here, we present a comprehensive assessment of the impact of variants B.1.1.7, B.1.351, P.1, B.1.429, and B.1.526 on binding, neutralizing, and ACE2-blocking antibodies elicited by the vaccine mRNA-1273 over seven months. Cross-reactive neutralizing responses were rare after a single dose of mRNA-1273. At the peak of response to the second dose, all subjects had robust responses to all variants. Binding and functional antibodies against variants persisted in most subjects, albeit at low levels, for 6 months after the primary series of mRNA-1273. Across all assays, B.1.351 had the greatest impact on antibody recognition, and B.1.1.7 the least. These data complement ongoing studies of clinical protection to inform the potential need for additional boost vaccinations.

ONE-SENTENCE SUMMARY

Most mRNA-1273 vaccinated individuals maintained binding and functional antibodies against SARS-CoV-2 variants for 6 months.

Altered Thalamocortical Connectivity in 6-Week-Old Infants at High Familial Risk for Autism Spectrum Disorder

Converging evidence from neuroimaging studies has revealed altered connectivity in cortical-subcortical networks in youth and adults with autism spectrum disorder (ASD). Comparatively little is known about the development of cortical-subcortical connectivity in infancy, before the emergence of overt ASD symptomatology. Here, we examined early functional and structural connectivity of thalamocortical networks in infants at high familial risk for ASD (HR) and low-risk controls (LR). Resting-state functional connectivity and diffusion tensor imaging data were acquired in 52 6-week-old infants. Functional connectivity was examined between 6 cortical seeds-prefrontal, motor, somatosensory, temporal, parietal, and occipital regions-and bilateral thalamus. We found significant thalamic-prefrontal underconnectivity, as well as thalamic-occipital and thalamic-motor overconnectivity in HR infants, relative to LR infants. Subsequent structural connectivity analyses also revealed atypical white matter integrity in thalamic-occipital tracts in HR infants, compared with LR infants. Notably, aberrant connectivity indices at 6 weeks predicted atypical social development between 9 and 36 months of age, as assessed with eye-tracking and diagnostic measures. These findings indicate that thalamocortical connectivity is disrupted at both the functional and structural level in HR infants as early as 6 weeks of age, providing a possible early marker of risk for ASD.

Variability in the Management of Adults With Pulmonary Nontuberculous Mycobacterial Disease

BACKGROUND

The increasing global prevalence of pulmonary nontuberculous mycobacteria (NTM) disease has called attention to challenges in NTM diagnosis and management. This study was conducted to understand management and outcomes of patients with pulmonary NTM disease at diverse centers across the United States.

METHODS

We conducted a 10-year (2005-2015) retrospective study at 7 Vaccine and Treatment Evaluation Units to evaluate pulmonary NTM treatment outcomes in human immunodeficiency virus-negative adults. Demographic and clinical information was abstracted through medical record review. Microbiologic and clinical cure were evaluated using previously defined criteria.

RESULTS

Of 297 patients diagnosed with pulmonary NTM, the most frequent NTM species were Mycobacterium avium-intracellulare complex (83.2%), M. kansasii (7.7%), and M. abscessus (3.4%). Two hundred forty-five (82.5%) patients received treatment, while 45 (15.2%) were followed without treatment. Eighty-six patients had available drug susceptibility results; of these, >40% exhibited resistance to rifampin, ethambutol, or amikacin. Of the 138 patients with adequate outcome data, 78 (56.5%) experienced clinical and/or microbiologic cure. Adherence to the American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) treatment guidelines was significantly more common in patients who were cured (odds ratio, 4.5, 95% confidence interval, 2.0-10.4; P < .001). Overall mortality was 15.7%.

CONCLUSIONS

Despite ATS/IDSA Guidelines, management of pulmonary NTM disease was heterogeneous and cure rates were relatively low. Further work is required to understand which patients are suitable for monitoring without treatment and the impact of antimicrobial therapy on pulmonary NTM morbidity and mortality.

Long-term cancer surveillance: results from the Forteo Patient Registry Surveillance Study

The Forteo Patient Registry estimated the incidence of osteosarcoma in US patients treated with teriparatide and enrolled in the study between 2009 and 2019. No incident cases of osteosarcoma were identified among patients registered, and the crude incidence rate was 0 (95% confidence interval [CI], 0-10.2) cases per million person-years.

PURPOSE

The prospective, voluntary Forteo Patient Registry was established to estimate the incidence of osteosarcoma in patients who have received treatment with teriparatide (Forteo).

METHODS

Information on US adults prescribed teriparatide and enrolled in the Forteo Patient Registry 2009-2019 was linked with data from participating state cancer registries annually (2010-2019) to identify incident osteosarcoma cases using a standardized linkage algorithm. Teriparatide exposure was ascertained from self-reported data that included teriparatide initiation and demographics necessary to complete linkage. Osteosarcoma cases diagnosed on or after January 1, 2009, were identified by participating state cancer registries. The crude incidence rate (IR) and standardized incidence ratio (SIR) of observed cases to the expected number of cases adjusted to the background rate (3 per million person-years) and corresponding 95% CIs for the occurrence of osteosarcoma were calculated whereby the cumulative amount of person-time observed was adjusted for mortality.

RESULTS

Data for 75,247 enrolled patients (representing 361,763 cumulative person-years) were linked to each of 42 participating state cancer registries (covering 93% of the US population), which included information on 6180 cases of osteosarcoma. No matches with incident cases of osteosarcoma following registry enrollment were found. The crude IR was 0 (95% CI, 0-10.2) cases per million person-years and the SIR was 0 (95% CI, 0-3.0).

CONCLUSIONS

The ability to draw conclusions about the incidence of osteosarcoma among patients participating in the registry was limited due to the smaller than expected amount of patient follow-up time and the fact that no cases were identified.

70 Improving the Documentation of DNACPR Decisions Following the Transition to Electronic Record Keeping

Background

This quality improvement project was based at The Royal Bolton Hospital across our four Complex Care wards.

Introduction

We have recently transferred to electronic record keeping. At these points of transition there may be an adverse impact on the quality of patient care and safety. We recognised on our own ward there were inaccuracies between the required paper form and electronic documentation of DNACPR decisions. Consequently, we wanted to review and improve the accuracy of our DNACPR documentation to ensure safe and effective patient care.

Methods

To gauge the scope of the problem we audited 87 patient’s electronic and paper notes, with no exclusion criteria. We reviewed whether each patient had a formal resuscitation decision, and if a DNACPR decision had been made whether we met our hospital policy by having:

93% of the 87 patient’s had an active decision regarding resuscitation, with a DNACPR decision documented for 50 patients. Of these 50 patients only 11 had all three forms of documentation. More worryingly, there were discrepancies in the documented DNACPR decisions for 11 patients across paper and electronic records.

Interventions

We escalated our concerns to the Clinical Governance team who sent out a trust wide SBAR highlighting this as an urgent clinical issue. On a directorate level we incorporated DNACPR decision documentation into our afternoon safety huddle and arranged informal teaching for medical, nursing and administrative staff.

Results

Reassuringly, the subsequent re-audit of 90 patient’s notes showed only one patient to have a discrepancy between paper and electronic documentation. We saw an improvement to 98% having paper forms in the right bedside notes and 100% having a documented electronic DNACPR decision.

Conclusion

Through local education and trust-wide dissemination of our expected standards we have seen some improvement. We recognise the importance of maintaining this, and importantly that there is still work to be done. The electronic “Resuscitation and treatment escalation plan” is still rarely completed and provides important information on escalation of care and thus will be the focus of a further educational intervention.

177. Safety of Measles and Pertussis-containing Vaccines in School-age Children Previously Diagnosed with Autism Spectrum Disorders

Background

Some parents, especially those of children with autism spectrum disorders (ASD), are uncertain about the safety of childhood immunization. We compared rates of fever, febrile seizure and emergency room (ER) visits following measles and pertussis-containing vaccines recommended between ages 4–6 years among children with and without ASD.

Methods

The study included children who were born between 1995–2012, aged 4–7 years at vaccination, and members of six integrated healthcare delivery systems within the Vaccine Safety Datalink. Children with ASD were defined based on receipt of two separate International Classification of Diseases (ICD)-9 or 10 codes. Outcomes (fever, febrile seizures, and ER visits) were identified in electronic health records. To minimize confounding by unmeasured factors related both to avoidance of vaccination and to outcomes of interest, we compared rates of each outcome between children with and without ASD, in risk and control intervals, by estimating the difference-in-differences on a log scale (i.e. the ratio of rate ratios) using logistic regressions. We also conducted risk interval analyses comparing rates of outcomes in risk intervals and control intervals within each group.

Results

The study included 14,947 children with ASD and 1,650,041 children without ASD. After measles or pertussis-containing vaccination, there were no differences in association between the two groups for fever or ER visits (Table). There were no febrile seizures identified among children with ASD. Within the ASD group, rates of fever, seizure or ER visits did not differ significantly between the risk and control intervals after vaccination. However, among the non-ASD group, measles and pertussis-containing vaccines were associated with higher rates of fever and seizure in risk intervals compared to controls intervals. Pertussis-containing vaccines were associated with increased risk of ER visits in risk interval compared to control interval (Table).

Conclusion

We found no difference in the risk of fever, and ER visits comparing children with autism to children without autism after measles or pertussis-containing vaccines. The study provides some reassurance that these vaccines are not less safe in children with ASD.

Disclosures

Lei Qian, PhD, GlaxoSmithKlein (Research Grant or Support) Nicola P. Klein, MD, PhD, GSK group of companies (Research Grant or Support)Merck (Grant/Research Support)Pfizer (Grant/Research Support)Protein Science (now SP) (Grant/Research Support)Sanofi Pasteur (Grant/Research Support)

Lack of neural evidence for implicit language learning in 9-month-old infants at high risk for autism

Word segmentation is a fundamental aspect of language learning, since identification of word boundaries in continuous speech must occur before the acquisition of word meanings can take place. We previously used functional magnetic resonance imaging (fMRI) to show that youth with autism spectrum disorder (ASD) are less sensitive to statistical and speech cues that guide implicit word segmentation. However, little is known about the neural mechanisms underlying this process during infancy and how this may be associated with ASD risk. Here, we examined early neural signatures of language-related learning in 9-month-old infants at high (HR) and low familial risk (LR) for ASD. During natural sleep, infants underwent fMRI while passively listening to three speech streams containing strong statistical and prosodic cues, strong statistical cues only, or minimal statistical cues to word boundaries. Compared to HR infants, LR infants showed greater activity in the left amygdala for the speech stream containing statistical and prosodic cues. While listening to this same speech stream, LR infants also showed more learning-related signal increases in left temporal regions as well as increasing functional connectivity between bilateral primary auditory cortex and right anterior insula. Importantly, learning-related signal increases at 9 months positively correlated with expressive language outcome at 36 months in both groups. In the HR group, greater signal increases were additionally associated with less severe ASD symptomatology at 36 months. These findings suggest that early differences in the neural networks underlying language learning may predict subsequent language development and altered trajectories associated with ASD risk.