Genetic overlap study between idiopathic pulmonary fibrosis and COVID-19

Background/Objectives: Genetic factors influence COVID-19 susceptibility and outcomes, including the development of pulmonary fibrosis (i.e. lung scarring). Idiopathic pulmonary fibrosis (IPF) is a progressive lung disease and the most common cause of pulmonary fibrosis in the general population. Genome-wide association studies (GWAS) of COVID-19 and IPF revealed genes associated with both diseases, suggesting these share genetic risk factors. Here we performed a genetic overlap study between COVID-19 and IPF. Method(s): Summary statistics from an IPF 5-way meta-GWAS and from the COVID-19 Host Genetics initiative GWAS metaanalysis (v6) were used. We performed genetic correlation analyses and assessed individual genetic signals to identify those variants shared between both traits. We conducted colocalisation analyses to determine whether the same causal variant was driving both traits. Finally, the association of overlapping variants with gene expression was assessed and a phenome-wide association study was performed. Result(s): There was a positive genetic correlation between severe COVID-19 and IPF. We found four genetic loci with likely shared causal variants between both traits, including one novel risk locus at 7q22.1 that colocalised with decreased ZKSCAN1 and TRIM4 expression in blood. The other three loci colocalised with MUC5B, ATP11A and DPP9 expression. The locus associated with increased ATP11A expression was also associated with higher Hb1AC levels, a biomarker used in diabetes. Conclusion(s): Results suggest there are shared biological processes driving IPF and severe COVID-19 phenotypes.

SHOT ON THE SPOT VACCINATION COMMUNITY OUTREACH

Due to the COVID-19 pandemic disproportionately affecting Black communities, The University of Alabama (UA) partnered with the Rural Alabama Prevention Center (RAPC), a community-based healthcare organization to improve the vaccination rate from 34% vaccinated Alabama Black Belt residents to 70% over a year. Health literacy training is provided to community health workers and students who, along with the team members, volunteer at pop-up Shot on the Spot vaccination sites to administer surveys collecting demographics and vaccine hesitancy data. Team members provide health literacy information and answer questions non-vaccinated individuals have. This vaccination intervention has led to drastic rate increases, such as, Choctaw County having a 36.6% increase since the beginning of the project in August (30.7% to 67.30%). However, some counties have low vaccination rate changes, such as, Crenshaw County with a rate change of 15.4% (19.5% to 34.90%). Notably, the Alabama Black Belt currently stands at a higher vaccination rate compared to Tuscaloosa County (UA's location), only having a rate of 44.3%. Within one year, there have been a total of 44 administered first and second vaccine doses and 435 booster doses, resulting in 50.24% vaccinated Black Belt residents. As the virus evolved into different variants, team members were able to observe an increase in administered booster doses in congruence with the rise of a new coronavirus variant. The partnership formed between RAPC and UA scientists and students is an important step in improving vaccination rates and building community research on minority and diverse populations.

Genetic overlap study between acute respiratory distress syndrome and idiopathic pulmonary fibrosis

Introduction and ObjectiveAcute respiratory distress syndrome (ARDS) is a critical lung condition induced by a systemic inflammatory response. A subset of ARDS patients can also develop pulmonary fibrosis (i.e. lung scarring). Idiopathic pulmonary fibrosis (IPF) is the most common cause of pulmonary fibrosis in the general population. Genome-wide association studies (GWAS) of IPF and post-sepsis ARDS suggest that these phenotypes could share genetic risk factors. Here we performed the first genetic overlap study between IPF and ARDS to identify shared genetic risk loci that might be informative about development of lung fibrosis after ARDS.MethodsWe used summary statistics from large meta-GWASs of IPF risk (4,125 cases, 20,464 controls) and post-sepsis ARDS (716 cases, 4,399 controls), as well as individual-level data from a subset of individuals from the ARDS GWAS (321 cases, 3,249 controls). We performed polygenic risk score (PRS) analyses to assess if IPF GWAS variants could be used to predict ARDS risk. We constructed PRSs as the weighted sum of variants reaching different p-value thresholds in the IPF meta-GWAS, and tested their association with ARDS risk, whilst adjusting for age, sex and population stratification. We also assessed individual genetic signals to identify variants shared between both traits. We conducted colocalisation analyses to determine whether the same causal variant was driving both phenotypes, and studied the association of overlapping variants with gene expression.ResultsThe PRS calculated from IPF variants that passed the best p-value threshold (i.e. p=0.0011) predicted ARDS risk (p=4.07x10-04, OR[95%CI]=1.24[1.10, 1.39]). We also found that the ARDS protective allele at HLA-DQA2 was associated with IPF risk (p=1.28x10-04) and that the IPF risk allele at ATP11A conferred protection from post-sepsis ARDS (p=0.003). The latter was associated with protection from severe COVID-19 in previous studies. Colocalisation analyses were inconclusive, likely due to the limited ARDS sample size.ConclusionsOur risk score analyses suggest that there may be shared biological processes underlying IPF and ARDS risk. However, we note opposite directions of effect on IPF and ARDS risk for some loci. Further studies are needed to assess if these results are also informative about fibrotic sequelae of ARDS.Please refer to page A208 for declarations of interest related to this .

Wasserstein-based texture analysis in radiomic studies.

The emerging field of radiomics that transforms standard-of-care images to quantifiable scalar statistics endeavors to reveal the information hidden in these macroscopic images. The concept of texture is widely used and essential in many radiomic-based studies. Practice usually reduces spatial multidimensional texture matrices, e.g., gray-level co-occurrence matrices (GLCMs), to summary scalar features. These statistical features have been demonstrated to be strongly correlated and tend to contribute redundant information; and does not account for the spatial information hidden in the multivariate texture matrices. This study proposes a novel pipeline to deal with spatial texture features in radiomic studies. A new set of textural features that preserve the spatial information inherent in GLCMs is proposed and used for classification purposes. The set of the new features uses the Wasserstein metric from optimal mass transport theory (OMT) to quantify the spatial similarity between samples within a given label class. In particular, based on a selected subset of texture GLCMs from the training cohort, we propose new representative spatial texture features, which we incorporate into a supervised image classification pipeline. The pipeline relies on the support vector machine (SVM) algorithm along with Bayesian optimization and the Wasserstein metric. The selection of the best GLCM references is considered for each classification label and is performed during the training phase of the SVM classifier using a Bayesian optimizer. We assume that sample fitness is defined based on closeness (in the sense of the Wasserstein metric) and high correlation (Spearman's rank sense) with other samples in the same class. Moreover, the newly defined spatial texture features consist of the Wasserstein distance between the optimally selected references and the remaining samples. We assessed the performance of the proposed classification pipeline in diagnosing the coronavirus disease 2019 (COVID-19) from computed tomographic (CT) images. To evaluate the proposed spatial features' added value, we compared the performance of the proposed classification pipeline with other SVM-based classifiers that account for different texture features, namely: statistical features only, optimized spatial features using Euclidean metric, non-optimized spatial features with Wasserstein metric. The proposed technique, which accounts for the optimized spatial texture feature with Wasserstein metric, shows great potential in classifying new COVID CT images that the algorithm has not seen in the training step. The MATLAB code of the proposed classification pipeline is made available. It can be used to find the best reference samples in other data cohorts, which can then be employed to build different prediction models.

The Role of Physiotherapy and Occupational Therapy in Post COVID-19 Critical Care Follow-Up Clinic Follow up clinic

Introduction: The COVID-19 pandemic brought about an influx of patients admitted to critical care with higher length of stay and rates of complications. The subsequent health burden related to impaired recovery is substantial, compounded by the multi-system effects of both critical illness and COVID-19 symptoms (FICM, 2019;NHS, 2021). Emerging evidence demonstrates that the associated combination of long-term physical, cognitive, psychological, and social difficulties are highly debilitating for survivors, impacting on their day-to-day function, identity, quality of life as well as the well-being of their families and carers (NHS, 2021). With significant pressure pushed onto existing respiratory and critical care teams, this has led to the development of a temporary critical care follow-up clinic with multidisciplinary support to address increased needs holistically. Objectives: The aim of this project was to: 1. highlight the value of having physiotherapy (PT) and occupational therapy (OT) input in COVID-19 critical care follow-up clinic 2. identify post COVID-19 critical care symptoms and issues conducive to the need for physiotherapy and occupational therapy support 3. identify gaps in services and establish community links to improve therapy access, and overall patient care and satisfaction Methods: The COVID-19 critical care follow-up clinic ran between March 2021 and August 2021. It aimed to review patients approximately three months post-discharge. The inclusion criteria involved anyone admitted to intensive care unit (ICU) with COVID-19 at any of the Barts Health NHS Trust sites. Patients who have a very short stay on intensive care, those with no impairments on hospital discharge, and those who were palliated were excluded. The multidisciplinary team included a critical care consultant, specialist nurse, physiotherapist, occupational therapist, and psychologist. Clinics ran consisted of four one-hour appointment slots with pre and post meeting and administration time. Results: A total of 66 clinics were completed during this time frame. Of the patients seen in clinic (n=221), over 50% were still struggling with global weakness, reduced exercise tolerance, fatigue, pain and breathlessness. Discussion: Themain post COVID ITU symptoms were those that linked directly to therapies, specifically fatigue, weakness, reduced mobility, and cognitive issues. Therefore, having specialist knowledge of these issues and the services that can help them within the MDT was imperative to ensuring these patients got the best care possible. The percentage of clinics ran with just OT/PT and a consultant, the number of therapies referrals, and the specialist advice provided clearly highlights the need for more permanent therapy input in COVID ITU clinics. Having a nurse and psychologist for a fully rounded MDT would be ideal, but it shows that therapists are an invaluable addition and should be a permanent fixture to any post ICU MDT team. Conclusion: The COVID-19 pandemic has highlighted the importance of holistic multidisciplinary team support in critical illness recovery, particularly the value of the role of physiotherapy and occupational therapy in COVID-19 critical care follow-up clinic is demonstrated in this project. Various therapy interventions were appropriate to addressing on-going symptoms and issues identified in the clinic. This clinic also provided insight onto gaps in existing services, such as rehabilitation for post intensive care acquired weakness.

Exclusion of Reproductive-aged Women in COVID-19 Vaccination and Clinical Trials.

INTRODUCTION: We analyzed the exclusion of pregnant and breastfeeding individuals and those capable of pregnancy in COVID-19 vaccine and clinical treatment trials. METHODS: Inclusion and exclusion criteria were extracted from all listed COVID-19 vaccine and treatment clinical trials from May 1, 2020, to October 31, 2020, using the U.S. National Library of Medicine database. We report rates of rates of exclusion for pregnant and lactating individuals and requirements for contraception for pregnancy-capable participants in COVID-19 vaccine and treatment clinical trials. The analysis included the association between clinical trial exclusion and vaccine and treatment type, study location, sponsor, and phase. RESULTS: Pregnant and lactating individuals were explicitly excluded from most COVID-19 vaccine and treatment clinical trials. Of the 90 vaccine trials, 88 (97.8%) excluded pregnant individuals, 73 (81.1%) excluded lactating individuals, and 56 (62.2%) required contraception use. Of the 495 treatment trials, 350 (70.7%) excluded pregnant individuals, 269 (54.3%) excluded lactating individuals, and 91 (18.4%) required contraception use. Although vaccine type was not associated with pregnancy exclusion, it was associated with lactation exclusion (p = .01) and contraception requirement (p < .001). Treatment type was associated with pregnancy exclusion, lactation exclusion, and contraception requirement (all p < .001). CONCLUSIONS: COVID-19 vaccination and treatment clinical trials mirrored historical trends restricting participation owing to pregnancy, lactation, and contraception nonuse, despite known safety profiles. People of childbearing potential should be considered for and afforded the same opportunity as males to make informed decisions on study participation, particularly in the setting of a global pandemic.

Outcomes Associated with Asthma Exacerbations with Respiratory Failure Treated with Extracorporeal Membrane Oxygenation

Rationale: Asthma affects 20 million adults in the United States resulting in up to 500,000 hospitalizations each year. Patients admitted to the intensive care unit (ICU) for asthma exacerbations requiring invasive ventilation have a mortality of ∼7%. Extracorporeal membrane oxygenation (ECMO) is a salvage technique used in patients with respiratory failure to increase delivery of oxygen, remove CO2 and allow time for recovery. Case series and uncontrolled registry studies have examined benefits of ECMO for asthma exacerbations with respiratory failure, but no studies have examined outcomes associated with use of ECMO for asthma exacerbations compared to standard care. Objective: To assess outcomes associated with use of ECMO during asthma exacerbations requiring invasive ventilation compared to standard care. Methods: Patients were extracted from the Premier Database from 2010-2020 if they had a primary diagnosis of asthma, or a primary diagnosis of respiratory failure with a secondary diagnosis of asthma, and were treated with invasive ventilation. Patients were excluded for age < 18y, no ICU admission, chronic lung disease other than asthma, COVID-19, or if they were not treated with corticosteroids. Hospital mortality was the primary study outcome. Key secondary outcomes included ICU length of stay (LOS), hospital LOS, length of invasive ventilation and hospital costs. Differences in outcomes were assessed using propensity score matching at a 1:2 ratio of ECMO versus no ECMO, and by covariate adjustment of the entire study group. Results: A total of 20,494 patients with asthma exacerbations requiring invasive ventilation were included in the study, of which 130 were treated with ECMO and 20,364 were not. After propensity matching, ECMO (N=103) versus no ECMO (N=206) was associated with reduced mortality (11.4% vs. 23.3%, p = 0.017) and increased hospital costs, but no difference in ICU LOS, hospital LOS or length of mechanical ventilation (Table). The covariate-adjusted model replicated these findings (Table). When individual patients were assigned a probability of being treated with ECMO equal to the hospital rate where they were admitted, each 10% increase in the hospital rate of ECMO was associated with no change in the odds of mortality (OR, 1.12: 95% CI, 0.82-1.52), p=0.48). ECMO was also associated with increased renal replacement therapy (P = 0.02), shock (P=0.02) and 30-day all-cause readmission (P = 0.01). Conclusion: ECMO was associated with reduced mortality at the cost of increased morbidity in asthmatics requiring invasive ventilation, indicating that ECMO has the potential to save thousands of lives.

Assessing Medical Student Competency in the Teleneurology Examination

Background: The CoVid-19 pandemic prompted U.S. medical schools to increasingly implement telemedicine curriculum in undergraduate medical education. The neurological exam is wellsuited to the virtual doctor's visit, which has been demonstrated by telestroke for many years. However, there are few established protocols for assessing medical students' proficiency at performing a telemedicine exam. Studies show that students view formal telemedicine training as valuable to their medical education. Design/Methods: We recruited voluntary third-year medical students from University of New Mexico School of Medicine. We developed an innovative scorecard to yield a “neurologicalexam-score” (NES). Students were assigned a patient on which both in-person and teleneurological examination was performed yielding a “Student in-person NES” and “Student teleneurology NES”. Students were randomly assigned to perform an in-person exam or the teleneurological exam first. A neurology faculty or resident also performed an in-person examination on the patient yielding a “Faculty/Resident NES,” our “gold standard”. We compared the [Faculty/Resident NES minus Student in-person NES] score to [Faculty/Resident NES minus Student teleneurology NES] score using a one-tailed t-test, where p <.05 is considered statistically significant. Results: Twenty-nine students participated in the study. Ten were excluded for incomplete examinations and/or lack of neurology faculty NES. Comparing students' in-person exam to teleneurological exam, we found no significant difference between students' scores (mean= -0.5, p=.21). In addition, both “student in-person NES” and “student teleneurology NES” significantly differed compared to neurology faculty/resident's NES scores (mean= 2.3, p<.0001 and mean= 1.8, p<.0001 respectively). Conclusions: Students performed similarly on a teleneurological examination compared to inperson neurological examination. The study was limited by low-power and was limited to a single class. Our study shows potential in incorporating a telemedicine curriculum within the third-year clerkships and supports developing a teleneurology curriculum in an objective manner.

Epilogue: What’s Next? A New Era

The global pandemic has challenged everything the authors thought they knew about international higher education. In many ways, the post-World War II era defined and made possible the Golden Age of International Higher Education, especially after the Cold War, with robust systems of education across the world and scholars, students moving to new places. The future is becoming more digital, whether they like it or not, so the sector will have to adjust to new innovations. These new realities were already encroaching on the sector prior to the pandemic, and the virus just likely sped up the changes at an unprecedented rate. This post-COVID era will see more digital commuting, flexible scheduling, and less traveling for work. The ability for students and scholars moving across the world to study, learn, or research will be even more coveted, though our sector should pay careful attention to who is afforded these opportunities. © 2022 selection and editorial matter, Krishna Bista, Ryan M. Allen, and Roy Y. Chan;individual chapters, the contributors.

A New Golden Age in International Higher Education: Challenges and Successes during the Pandemic and Beyond

This introductory chapter responds to the growing need for new insights and perspectives to improve global student mobility policy and practice in the era of COVID-19. Specifically, this chapter gives an overview of the book and draws an outline of the impacts for global mobility in the field of comparative and international higher education. We highlight international student trends and the need for developing programs, policies, and systems that align with national needs, institutional priorities, and student well-being for global learning. © 2022 selection and editorial matter, Krishna Bista, Ryan M. Allen, and Roy Y. Chan;individual chapters, the contributors.

Impacts of COVID-19 on International Students and the Future of Student Mobility: International Perspectives and Experiences

This volume uses case studies and students’ lived experiences to document the impacts of coronavirus (COVID-19) on international students and explore future challenges and opportunities for student mobility within higher education. Responding to the growing need for new insights and perspectives to improve higher education policy and practice in the era of COVID-19, this text analyses the changing roles and responsibilities of institutions and international education leaders post-2020. Initial chapters highlight key issues for students that have arisen as a result of the global health crisis such as learning, well-being, and the changed emotional, legal, and financial implications of study abroad. Subsequent chapters confront potential longer-term implications of students’ experiences during COVID-19, and provide critical reflection on internationalization and the opportunities that COVID-19 has presented for tertiary education systems around the world to learn from one another. This timely volume will benefit researchers, academics, and educators with an interest in online teaching and e-learning, curriculum design, and more specifically those involved with international and comparative education. Those involved with educational policy and practice, specifically related to pandemic education, will also benefit from this volume. © 2022 selection and editorial matter, Krishna Bista, Ryan M. Allen, and Roy Y. Chan;individual chapters, the contributors.

Protecting the University as a Physical Place in the Age of Postdigitization

Covid-19 forced higher education sectors across the world to digitize the entire university experience online. There are now calls for universities to continue chasing continued and further digitization, often from for-profit businesses and those in Silicon Valley who have been promising to disrupt the sector for decades. We argue that the pandemic has illustrated how crucial universities are to their local communities, and efforts should be made to emphasize their physical place and space. The destruction of American cities in favor of auto-centric suburbs provides a parallel for the possible future of higher education. The Cult of Efficiency mindset and accountability models that dominated neoliberal discourse offered the impetus for highway construction through city centers, often razing Black neighborhoods and ruining communities and culture along the way. The calls for the full digitization of universities echo this same possible destruction for the sector. This is not a Luddite warning to reject all digitization, instead, it is a rejection of the hyper-capitalization of higher education and the disruption promised by for-profit businesses, along with a reminder that the sector should be a local public good. © 2021, The Author(s), under exclusive licence to Springer Nature Switzerland AG.

A retrospective service evaluation of a virtual respiratory physiotherapy outpatient clinical service

Keywords: Virtual;Airway clearance;Outpatients Purpose: The COVID 19 pandemic at the start of 2020 resulted in non-urgent outpatient services being temporarily cancelled. Following national guidance our respiratory outpatient service was challenged on how it could be provided virtually. Telephone clinics emerged as a solution however this would not allow for effective assessment, teaching and modifying a patient's airway clearance technique (ACT). The use of virtual clinics within other specialities, i.e. CF is already being used successfully. Aim: To review the effectiveness of a virtual service delivery for Airway Clearance in a chronic respiratory population and to guide future use of technology in outpatient services. Methods: We conducted a retrospective audit of virtual provision of Airway Clearance to a respiratory outpatient population. Patients’ attendance and outcomes were reviews. Results: Forty-seven 47 patients (36% male, mean (SD) age 57 (16)) were referred to the respiratory outpatient physiotherapy service to establish an ACT between March 2020 and 2021. 70% were diagnosed with bronchiectasis. 87% attended appointments virtually with 74% via video call. To establish an effective ACT, it took 2 appointments of 30 min. 58% (24) were taught acapella, 40% (16) ACBT and 2% (1) another ACT. 5% (2) of patients did not have English as their first language, nor a family member present, and required advocates to translate during the appointment. Of those who attended virtually, 1 patient was admitted to hospital within 3 months of being discharged from the service with an infective exacerbation of bronchiectasis. 6% (3/47) declined a virtual consultation with their main reason being access to technology (60% male, mean (SD) age 46 (3)). Our DNA rate was 18%. Conclusion(s): Our findings indicate that virtual clinics are feasible for respiratory assessments and teaching an ACT. Patients could be taught different types of airway clearance within a few appointments, with no adverse events. The impact of the COVID pandemic resulted in changes to outpatient services occurring with immediate effect therefore it is difficult to compare these outcomes to face to face clinics from previous years. As face to face appointments were unavailable, patients had limited choice on their appointment type during this time period However this change in practice helps overcome other historical barriers for face to face appointments that were being faced prior to the pandemic, i.e. Travel distance and cost, infection control, time off work. Admission rates may have also been lower due to a variety of reasons, including shielding resulting in reduced exposure, reluctance from patients to be admitted to hospital. They do not reflect exacerbations managed at home via GP's. Barriers identified were around access to technology. Further work is required to identify if there is long term carry over and effectiveness of these treatments. Qualitative data on patient's perceptions of a virtual clinic would be valuable to guide any long term changes to the service. Impact: The project has enabled a service design change that may improve better access to our respiratory outpatient service. It also indicates a potential path for digital transformation within respiratory outpatient physiotherapy. Funding acknowledgements: The work was not funded.

De novo or recurrent glomerulonephritis and acute tubulointerstitial nephritis after COVID-19 vaccination: A report of six cases from a single center.

Billions of COVID-19 vaccine doses have been administered to combat the ongoing global pandemic caused by severe acute respiratory syndrome coronavirus-2. While these vaccines are considered safe, with most adverse events being mild to moderate and transient, uncommon systemic side effects of the vaccines, including de novo or re-activation of various glomerular diseases have recently been observed. We report 6 patients who developed glomerular or acute tubulointerstitial disease shortly after receiving COVID-19 vaccinations. Five of these patients received mRNA vaccines (3 Moderna, 2 Pfizer-BioNTech) and 1 received adenovirus-26 vector vaccine (Johnson and Johnson/Janssen). Four of our patients developed de novo glomerulonephritis or acute tubulointerstitial nephritis (ATIN), while the other 2 had re-activation of prior glomerulonephritis. Two patients presented with acute kidney injury (AKI) characterized by severe ATIN. While both of them also had evidence of immune complex glomerular disease, ATIN was the dominant feature on the biopsies. Two other patients presented with high-grade proteinuria and AKI. Like the aforementioned patients, these patients had evidence of immune complex glomerular disease, but acute onset nephrotic syndrome was the leading clinical feature. Another patient presented with de novo myeloperoxidase-anti-neutrophil-cytoplasmic-antibody-associated pauci-immune crescentic glomerulonephritis. Yet another patient had re-activation of immunoglobulin-A glomerulonephritis that had been quiescent for several years prior to the vaccination. It is difficult to ascertain any causal relationship between COVID-19 vaccination and onset/recurrence of kidney diseases. However, vigilance about occurrence of such complications is imperative. Importantly, all our cases responded well to the immunosuppressive treatment.

A retrospective service evaluation of a virtual respiratory physiotherapy outpatient clinical service

P68 Figure 1total virtual and telephone % virtual telephone Number taught acapella 24 58% 22 2 Number taught ACBT 16 40% 12 4 Number taught other 1 2% 1 0 DiscussionOur findings indicate that virtual clinics are feasible for respiratory assessments and teaching an ACT. Patients could be taught different types of ACT within a few appointments, with no adverse events. The impact of the COVID pandemic resulted in changes to outpatient services with an immediate effect. Therefore patients had limited choice on their appointment type and so it is difficult to compare these outcomes to face to face clinics from previous years. This change in practice did overcome other historical barriers prior to the pandemic ie. Travel distance and cost and infection control. Admission rates may have been lower due to shielding, resulting in reduced exposure. They do not reflect exacerbations managed at home via GP’s.Further work is required to identify the long term carry over and effectiveness of these treatments. Qualitative data on patient’s perceptions of a virtual clinic would guide any long term changes to the service.ConclusionVirtual outpatient clinics for respiratory physiotherapy are feasible. The change in service design may improve access to our service and indicates a potential path for digital transformation within respiratory outpatient physiotherapy.

Evaluating the Impact of a Pilot Nationwide Webinar Series on National Med-Peds Residents' Association Membership.

BACKGROUND: As the COVID-19 pandemic significantly reduced the ability of medical students to travel and interact directly with combined Internal Medicine-Pediatrics (Med-Peds) residency programs, medical students desiring appropriate guidance and information about Med-Peds residency training needed a national forum for information during an unprecedented virtual recruitment year. OBJECTIVE: To develop a nationally coordinated webinar series for medical students and student advisors to learn about the Med-Peds specialty for residency training to keep applicant numbers and applicant interest from significantly falling. METHODS: A national webinar series focusing on general Med-Peds information, career interests, and tailored advising was created amongst the three national Med-Peds organizations over a three-month period in Spring 2020. RESULTS: There was a 221% increase in medical student membership to the National Med-Peds Residents' Association (NMPRA) compared to the same months in 2017, 2018, and 2019 and no significant reduction in the Electronic Residency Application Service® applications to Med-Peds programs over that same time period. CONCLUSIONS: A national forum for medical students inquiring about the combined Med-Peds specialty can be effective in recruiting members to NMPRA and keeping interest high in Med-Peds.

"To Fix a Broken Heart": An Unusual Case of Infective Endocarditis Involving the Mitral Valve With Perforation and Hemodynamic Instability.

Infective endocarditis (IE), commonly caused by Staphylococcus aureus, can affect multiple cardiac structures and lead to significant morbidity and mortality. We present a case of IE with extensive mitral valve involvement causing perforation and hemodynamic compromise. A 66-year-old Caucasian female presented to the emergency department for progressive altered mental status and lethargy. The patient and family denied history of intravenous drug use (IVDU) on interview. Physical exam revealed tachypnea, tachycardia, lethargy, and fluctuance in the right antecubital fossa draining serous fluid. Initial studies revealed a urinary tract infection, patchy bilateral opacities on chest x-ray, hypoxic respiratory failure, elevated lactate and cardiac markers, leukocytosis, and positive urine toxicology for opioid and benzodiazepine. She was intubated and admitted to the ICU, and later developed acute respiratory distress syndrome with requirement for vasopressors. Antibiotics were started, and blood cultures ultimately grew methicillin-sensitive S. aureus. Coronavirus disease 2019 (COVID-19) results were negative. Cardiology was consulted for elevated cardiac markers that were due to myocardial injury in the setting of septic shock. A transthoracic echocardiogram showed a large mobile mass on the anterior mitral leaflet. Further evaluation with transesophageal echocardiogram revealed a large, mobile, and centrally necrotic vegetation on the medial portion of the mitral annulus extending to both the anterior and posterior leaflets. Doppler of the valve showed holosystolic retrograde ejection into the left atrium confirming a perforation. The patient was transferred urgently to a cardiothoracic surgery capable center for operative intervention on the mitral valve. IE is most commonly caused by S. aureus and seen in highest rates among patients with a prosthetic valve, congenital heart disease, and intracardiac device. However, roughly 50% of IE occurs in patients without any valvular disease. Other risk factors include IVDU, valvular disease, and prior history of endocarditis. Clinical diagnosis of IE is made using the Duke's criteria, with echocardiogram and bacteremia playing a major role. The initial management involves empiric antibiotics until a pathogen is identified. Surgical consult is also suggested, and indications for surgery include heart failure due to valve dysfunction, uncontrolled infection, prevention of embolism, and hemodynamic compromise. Prompt recognition and intervention is crucial in the prevention of mortality in patients with IE leading to mitral perforation and hemodynamic compromise.