York City Health Research Articles

Mentorship and the Minority Experience Within the Nursing Profession: Identifying and Developing Programs to Address the Challenges and Barriers to Advancement Facing Minority Nurses and Nurse Leaders

New York City Health + Hospitals (NYC H+H) is the largest public health care system in the United States, safeguarding some 1.4 million patients annually; its 9600+ nurses are charged with delivering essential healthcare to the most vulnerable and disadvantaged members of society. NYC H+H is forging foundational transformation with an innovative, 3-tiered nurse mentorship program addressing the current imbalance between the demographics of the general population and the corresponding racial and ethnic composition of the nursing profession, as well as supporting the goals of promoting diversity and inclusion; eliminating health disparities, and serving disparate demographic populations with care and compassion.

Housing type and secondhand tobacco smoke exposure among non-smoking New York City adults, 2004 and 2013–14

Secondhand tobacco smoke (SHS) exposure has declined due to smoking reductions, expanding workplace and public smoke-free air laws, and smoke-free housing policy promotion. Population-based studies examining objective SHS exposure biomarkers have documented reductions over time, however non-smoking urban adults are more likely to have elevated cotinine (a metabolite of nicotine) compared with national averages. Evidence suggests residential housing type may impact urban SHS exposure risk. Direct associations between multiunit housing (MUH) and elevated cotinine have been identified among children but not yet examined among adults. We used data from the cross-sectional 2004 and 2013/14 New York City Health and Nutrition Examination Surveys to investigate associations between MUH (single-family versus 2; 3–99; and 100 + units) and likelihood of elevated serum cotinine among nonsmoking adults (2004: n = 1324; 2013/14: n = 946), adjusting for socio-demographics (sex, age, race/ethnicity, education, income) and self-reported SHS exposure variables. Combined and single-year adjusted multivariable regressions were conducted. Elevated cotinine was defined as a serum level of ≥ 0.05 ng/ml. Combined year adjusted multivariable regression analyses found no difference in elevated cotinine by housing type among non-smoking adults. By survey year, elevated cotinine did not vary by housing type in 2004, while non-smoking adults in 3–99 unit buildings were twice as likely to have elevated cotinine compared with single family residents in 2013/14 (adjusted Odds Ratio = 2.55 (1.13, 5.79)). While SHS exposure has declined, relative burden may be increasing among MUH residents. In urban settings with extensive MUH, attention to housing-based policies and programmatic interventions is critical to reducing SHS exposure.

Innovations in Fatality Management During the COVID-19 Pandemic.

Innovations in Fatality Management During the COVID-19 Pandemic.

Emergency Ambulance Utilization in Harlem, New York (July 1985)

Emergency ambulance service in Harlem, New York was studied to determine the degree to which misuse exists. Data were collected prospectively from a paramedic (ALS) ambulance and a basic life support (BLS) ambulance dispatched from Harlem Hospital. The results show that only 29.5% of the 136 calls dispatched to the ALS unit had congruent dispatch and actual priorities (r = 0.05), and only 59.6% of the 255 calls handled by both units were recommended for the unit with the proper level of the skill. 69.9% of calls assigned to the ALS unit were found not to need emergency transport (ET), the most common reason being the “unfounded” call, which represented 35.3% of the sample. ALS intervention was needed on only 20.6% of calls dispatched to the ALS unit. Paramedics were able to correctly access the need for ET 95.6% of the time, but were only willing to refuse transport 35.2% of times in which they felt it was unnecessary. Within the population studied, there exists a significant subset of nonemergency calls which could be more efficiently triaged, both at the level of dispatch and by EMS personnel on the scene. Author Perspective: This research was performed from July 1 to July 26, 1985 to fulfill the requirements of a Community Medicine rotation when the investigator was a student at the Mount Sinai School of Medicine in New York City (presently the Ican School of Medicine at Mount Sinai). Dr. Alexander E. Kuehl was the Vice President of New York City Health and Hospitals Corporation, Emergency Medical Service at the time (prior to New York City EMS moving under the Fire Department) and served as preceptor for the project. This work has not been previously published; however, the investigator was an invited presenter at the “Third International Urban Emergency Medical Service System Symposium” in September 1985 at the World Trade Center in New York City. The oral presentations at the symposium were entitled: “Paramedic Attitudes Concerning On-The-Scene Triage” and “Emergency Ambulance Utilization in Harlem.” To complete the work for this 30-day rotation, the investigator performed daily ambulance ride-alongs in Harlem, New York for 15 consecutive days and collected data prospectively from paramedics. EMTs staffing an ambulance during the same time frame provided concurrent information by survey. Some EMS terminology is now outdated; however, the terms have not been updated in order to preserve the historical perspective of the article. While the data are now historical, having been collected nearly 40 years ago, this research provides useful insights into current EMS initiatives, notably: (1) accuracy of assigned dispatch priority, (2) need for emergency transport to an emergency department, and (3) willingness of paramedics to refuse transport in cases where it is deemed unnecessary. The research questions represent many of the challenges that persist in today’s EMS world with some being particularly relevant with the advent of Community Paramedicine. Emergency Ambulance Utilization in Harlem truly illustrates “what’s old is new again!”

Lung cancer incidence among world trade center rescue and recovery workers.

BackgroundMany World Trade Center disaster (WTC) rescue and recovery workers (WTC RRWV) were exposed to toxic inhalable particles. The impact of WTC exposures on lung cancer risk is unclear.MethodsData from the WTC Health Program General Responders Cohort (WTCGRC) were linked to health information from a large New York City health system to identify incident lung cancer cases. Incidence rates for lung cancer were then calculated. As a comparison group, we created a microsimulation model that generated expected lung cancer incidence rates for a WTC‐ and occupationally‐unexposed cohort with similar characteristics. We also fitted a Poisson regression model to determine specific lung cancer risk factors for WTC RRWV.ResultsThe incidence of lung cancer for WTC RRWV was 39.5 (95% confidence interval [CI]: 30.7–49.9) per 100,000 person‐years. When compared to the simulated unexposed cohort, no significant elevation in incidence was found among WTC RRWV (incidence rate ratio [IRR] 1.34; 95% CI: 0.92–1.96). Predictors of lung cancer incidence included age, smoking intensity, and years since quitting for former smokers. In adjusted models evaluating airway obstruction and individual pre‐WTC occupational exposures, only mineral dust work was associated with lung cancer risk (IRR: 2.03; 95% CI: 1.07–3.86).DiscussionIn a sample from a large, prospective cohort of WTC RRWV we found a lung cancer incidence rate that was similar to that expected of a WTC‐ and occupationally‐unexposed cohort with similar individual risk profiles. Guideline‐concordant lung cancer surveillance and periodic evaluations of population‐level lung cancer risk should continue in this group.

Obesity, Inflammation, and Mortality in COVID-19: An Observational Study from the Public Health Care System of New York City.

Severe obesity increases the risk for negative outcomes in patients with coronavirus disease 2019 (COVID-19). Our objectives were to investigate the effect of BMI on in-hospital outcomes in our New York City Health and Hospitals’ ethnically diverse population, further explore this effect by age, sex, race/ethnicity, and timing of admission, and, given the relationship between COVID-19 and hyperinflammation, assess the concentrations of markers of systemic inflammation in different BMI groups. A retrospective study was conducted in hospitalized patients with COVID-19 in the public health care system of New York City from 1 March 2020 to 31 October 2020. A total of 8833 patients were included in this analysis (women: 3593, median age: 62 years). The median body mass index (BMI) was 27.9 kg/m2. Both overweight and obesity were independently associated with in-hospital death. The association of overweight and obesity with death appeared to be stronger in men, younger patients, and individuals of Hispanic ethnicity. We did not observe higher concentrations of inflammatory markers in patients with obesity as compared to those without obesity. In conclusion, overweight and obesity were independently associated with in-hospital death. Obesity was not associated with higher concentrations of inflammatory markers.

In-Person vs Electronic Directly Observed Therapy for Tuberculosis Treatment Adherence

Electronic directly observed therapy (DOT) is used increasingly as an alternative to in-person DOT for monitoring tuberculosis treatment. Evidence supporting its efficacy is limited. To determine whether electronic DOT can attain a level of treatment observation as favorable as in-person DOT. This was a 2-period crossover, noninferiority trial with initial randomization to electronic or in-person DOT at the time outpatient tuberculosis treatment began. The trial enrolled 216 participants with physician-suspected or bacteriologically confirmed tuberculosis from July 2017 to October 2019 in 4 clinics operated by the New York City Health Department. Data analysis was conducted between March 2020 and April 2021. Participants were asked to complete 20 medication doses using 1 DOT method, then switched methods for another 20 doses. With in-person therapy, participants chose clinic or community-based DOT; with electronic DOT, participants chose live video-conferencing or recorded videos. Difference between the percentage of medication doses participants were observed to completely ingest with in-person DOT and with electronic DOT. Noninferiority was demonstrated if the upper 95% confidence limit of the difference was 10% or less. We estimated the percentage of completed doses using a logistic mixed effects model, run in 4 modes: modified intention-to-treat, per-protocol, per-protocol with 85% or more of doses conforming to the randomization assignment, and empirical. Confidence intervals were estimated by bootstrapping (with 1000 replicates). There were 173 participants in each crossover period (median age, 40 years [range, 16-86 years]; 140 [66%] men; 80 [37%] Asian and Pacific Islander, 43 [20%] Black, and 71 [33%] Hispanic individuals) evaluated with the model in the modified intention-to-treat analytic mode. The percentage of completed doses with in-person DOT was 87.2% (95% CI, 84.6%-89.9%) vs 89.8% (95% CI, 87.5%-92.1%) with electronic DOT. The percentage difference was -2.6% (95% CI, -4.8% to -0.3%), consistent with a conclusion of noninferiority. The 3 other analytic modes yielded equivalent conclusions, with percentage differences ranging from -4.9% to -1.9%. In this trial, the percentage of completed doses under electronic DOT was noninferior to that under in-person DOT. This trial provides evidence supporting the efficacy of this digital adherence technology, and for the inclusion of electronic DOT in the standard of care. ClinicalTrials.gov Identifier: NCT03266003.

Hispanic race is a risk factor for COVID-19 during pregnancy: data from an urban New York City hospital

There are limited studies on predisposing factors for COVID-19 positivity in asymptomatic pregnant women. The literature published to date on asymptomatic COVID-19 pregnant carriers does not focus on pregnancy or pre-pregnancy comorbidities. We wanted to identify risk factors for COVID-19 in asymptomatic pregnant women. We performed a retrospective chart review of 263 asymptomatic pregnant women admitted to labour and delivery at New York City Health + Hospitals/Lincoln. We analysed the association between race, body mass index (BMI), smoking, indication for admission, gravidity, parity, pre-pregnancy comorbidity, pregnancy comorbidity via uni- and multivariate statistical tests. Only Hispanic race was significant in the univariate analysis (p = .049). At the post-hoc analysis, Hispanics had a higher proportion of COVID-19 cases compared to non-Hispanic Blacks (p = .019). No variables were significantly associated with COVID-19 positivity in the multivariate analysis. Hispanic race appears to be a risk factor for asymptomatic COVID-19 infection during pregnancy. We speculate that the cultural and socioeconomic reality of Hispanic women living in our community leads to more exposure opportunities and therefore, a higher infection rate. Impact statement What is already known on this subject? Little is known on the role of comorbidities and risk factors that can favour COVID-19 infection during pregnancy. What do the results of this study add? We found that Hispanic pregnant asymptomatic women had a higher rate of COVID-19 in comparison to non-Hispanic Black women. Pre-pregnancy comorbidities such as pregestational diabetes, hypertension and asthma were not associated with COVID-19 positivity. What are the implications of these findings for clinical practice and/or further research? The reasons why the Hispanic race is more affected by COVID-19 during pregnancy is unclear. The social environment of Hispanic women living in our community, such as their tendency to live in multigenerational and multi-family households, might contribute to a higher infection rate. More resources might be dedicated in the future to Hispanic-dense neighbourhoods.

Community-Informed Mobile COVID-19 Testing Model to Addressing Health Inequities.

The New York City (NYC) Test & Trace Corps (Test & Trace), under New York City Health + Hospitals (NYC H+H), set out to provide universal access to COVID-19 testing. Test & Trace partnered with numerous organizations to direct mobile COVID-19 testing from concept through implementation to reduce COVID-19-related health inequities. Test & Trace employs a community-informed mobile COVID-19 testing model to deliver testing to the hardest-hit, underserved communities. Community partners, uniquely knowledgeable of the residents they serve, are engaged as decision makers and operational partners in mobile COVID-19 testing delivery. Through several mobile testing methods, community partners choose testing locations and tailor outreach to their community. Test & Trace assumes logistical responsibility for mobile testing but defers critical programmatic decisions and community engagement to partners. Integral to the success of this program is responsive, bidirectional communication. During the reporting period of December 1, 2020, to April 30, 2021, Test & Trace's community-informed mobile COVID-19 testing model provided testing to 150351 unique patients and processed 274083 tests in total. The available outcomes data and qualitative feedback provided by community partners illustrate that this intervention, combined with robust governmental investment, successfully ensured that NYC-identified, low-resource neighborhoods had greater access to COVID-19 testing. Making community partners decision makers reduced inequities in access to testing for communities of color. In addition, the model has served as the framework for Test & Trace's community-informed mobile COVID-19 vaccination program, operated in concert with NYC's Vaccine Command Center, and is a foundation for addressing health inequities at scale, including during public health crises.

The impact of COVID-19 on Diabetic Ketoacidosis patients

Background and aimDescribe the prevalence/outcomes of Diabetic Ketoacidosis (DKA) patients comparing pre- (March–April 2019) and pandemic (March–April 2020) periods. MethodsRetrospective cohort of admitted pandemic DKA/COVID-19+ patients comparing prevalence/outcomes to pre-pandemic DKA patients that takes place in Eleven hospitals of New York City Health & Hospitals. Our included participants during the pandemic period were admitted COVID-19+ patients (>18 years) and during the pre-pandemic period were admissions (>18 years) selected through the medical record. We excluded transfers during both periods. The intervention was COVID-19+ by PCR testing. The main outcome measured was mortality during the index hospitalization and secondary outcomes were demographics, medical histories and triage vital signs, and laboratory tests. Definition of DKA: Beta-Hydroxybutyrate (BHBA) (>0.4 mmol/L) and bicarbonate (<15 mmol/L) or pH (<7.3). ResultsDemographics and past medical histories were similar during the pre-pandemic (n = 6938) vs. pandemic (n = 7962) periods. DKA prevalence was greater during pandemic (3.14%, 2.66–3.68) vs. pre-pandemic period (0.72%, 0.54–0.95) (p > 0.001). DKA/COVID-19+ mortality rates were greater (46.3% (38.4–54.3) vs. pre-pandemic period (18%, 8.6–31.4) (p < 0.001). Surviving vs. non-surviving DKA/COVID-19+ patients had more severe DKA with lower bicarbonates by 2.7 mmol/L (1.0–4.5) (p < 0.001) and higher both Anion Gaps by 3.0 mmol/L (0.2–6.3) and BHBA by 2.1 mmol/L (1.2–3.1) (p < 0.001). ConclusionsCOVID-19 increased the prevalence of DKA with higher mortality rates secondary to COVID-19 severity, not DKA. We suggest DKA screening all COVID-19+ patients and prioritizing ICU DKA/COVID-19+ with low oxygen saturation, blood pressures, or renal insufficiency.

Using Public Deliberation to Set Priorities: The Case of COVID-19 Vaccine Access in New York City.

The COVID-19 pandemic has resulted in a record number of deaths in the United States and tremendous economic and personal strain. During 2020, in anticipation of a vaccine to slow the spread of disease, local and state governments in the United States developed plans for vaccine prioritization, given a limited initial supply. Recognizing the challenges inherent in prioritization, the New York City (NYC) health department sought guidance from members of the public about the fairest approach to early-stage vaccine distribution. To solicit recommendations from NYC residents on priorities regarding vaccine access for essential worker occupations, considering risk factors and preferred approaches to fairness. Five public deliberations were conducted with NYC residents (N = 91). Participants heard presentations on the COVID-19 vaccine, the local distribution of illness and death, and approaches to fairness in the context of deliberating on priorities for 6 essential worker occupations and 4 risk factors. Discussions were transcribed, and transcriptions were coded and analyzed using preidentified and emergent themes. Pre- and post-surveys, focused on factors relevant to prioritization, were administered during each public deliberation. Recommendations for prioritization emphasized risk of severe morbidity and mortality, and work and neighborhood conditions with fewer protections (eg, in-person work, exposure to many people). Participants prioritized elementary schoolteachers, grocery store workers, and bus drivers, underlying health conditions, and neighborhood of residence. Participants focused on equity, recognizing that those at highest risk were largely low-income populations of color and individuals living in low-resourced neighborhoods. Participants' focus on equity, and acknowledgment of racial and ethnic disparities, revealed a nuanced understanding of the broader determinants of health. Recommendations reinforced the NYC health department's approach to vaccine distribution. Results from these public deliberations confirmed community support for approaches prioritizing health equity, recognizing both societal and personal factors affecting vulnerability to poor health.

Prescription smoking-cessation medication pharmacy claims after stroke and transient ischemic attack

Smoking cessation is critical in secondary prevention after stroke and transient ischemic attack. Data regarding use of smoking-cessation interventions after stroke and transient ischemic attack are sparse. We examined the use of prescription smoking-cessation medications in these patients. This is a retrospective cohort study using 2013–2016 data from the INSIGHT Clinical Research Network, comprised of Medicare prescription claims data merged with electronic health record data for patients receiving care across five New York City health care institutions. Active smoking was ascertained based on a validated ICD-9-CM diagnosis code or the presence of an electronic health record active smoking indicator, reflecting clinician-entered data in the health record. The primary outcome was a claim for any prescription smoking-cessation medication (varenicline or bupropion) within 12 months of hospital discharge. We evaluated claims for any statin medication as a comparator because statins are a standard component of stroke secondary prevention. We identified 3,153 patients with stroke or transient ischemic attack who were active smokers at the time of their event. Among these patients, 3.1% (95% CI, 2.5–3.9) had a pharmacy claim for a prescription smoking-cessation medication at 6 months, and 4.7% (95% CI, 3.9–5.6) did at 12 months hospital discharge. In contrast, cumulative statin medication claims rates were 67.5% (95% CI, 65.5–69.5%) at 6 months and 74.6% (95% CI, 72.7–76.6%) at 12 months. Prescription smoking-cessation medications were infrequently used after stroke and transient ischemic attack.

Chairside Diabetes Screening: A Survey of Dental Providers at the Largest Municipal Healthcare System in the United States.

To assess the knowledge and attitudes of dentists at the largest municipal healthcare system in the United States with regard to point-of-care chairside diabetes testing in the dental clinic. A 29-item survey was designed in a web-based platform (Survey Monkey) and distributed in November 2020 to 264 dental providers (attending dentists and residents) within eleven dental departments of the New York City Health + Hospitals municipal healthcare system. The questionnaire included sections on demographics, current practices, level of diabetes training, scope of practice, and attitudes regarding chairside diabetes testing. Descriptive statistics, bivariate analyses, and logistic regression analyses were performed, with statistical significance set at 0.05. Dentists' willingness to provide chairside HbA1c screening was positively associated with their agreement that this was part of their role (OR = 7.2, p = 0.001) and that screening has an impact on diabetes control (OR = 4.3, p = 0.04). The two most commonly reported barriers to willingness to provide chairside HbA1c screening were amount of time required to obtain and discuss a patient's test results (82.3%) and lack of reimbursement (70.6%). Among the largest municipal healthcare systems in the US, there is very limited integration of diabetes screening and management in the dental setting. Given the epidemic of diabetes among the vulnerable population that these hospitals serve, the dental setting is a critical but underutilized site for diabetes screening and medical referral. Increased efforts should be directed towards implementing workflows that incorporate auxiliary dental staff in order to address barriers to chairside screening.

When New York City was the COVID-19 pandemic epicenter: The impact on trauma care.

During early spring 2020, New York City (NYC) rapidly became the first US epicenter of the COVID-19 pandemic. With an unparalleled strain on health care resources, we sought to investigate the impact of the pandemic on trauma visits and mortality in the United States' largest municipal hospital system. We conducted a retrospective multicenter cohort study of the five level 1 trauma centers in NYC's public health care system, New York City's Health and Hospitals Corporation. Clinical characteristics, mechanism of injury, and mortality of trauma patients presenting during the early pandemic (March 1, 2020, to May 31, 2020) were compared with a similar period in the previous 2 years. To account for important patient and hospital-level confounding variables, we created a propensity score for treatment and applied inverse probability weighting. In March to May 2020, there was a 25% decrease in median number of monthly trauma visits (693 vs. 528; p = 0.02) but a 50% increase (15% vs. 22%; p = <0.001) in patients presenting for penetrating injuries, compared with the same period for 2018 and 2019. Injured patients with COVID were significantly more likely to die compared with those without COVID-19 (10.5% vs. 3.6%; p < 0.001). Overall, there was no significant difference in mortality for non-COVID-injured New Yorkers cared for in 2020 compared with 2018 and 2019. Less severely injured non-COVID patients (Injury Severity Score, <15), however, were significantly more likely to die compared with this same subgroup in 2018 and 2019 (adjusted relative risk, 2.7 [95% confidence interval, 1.5-4.7]). Despite a decline in overall trauma visits during the early part of the COVID pandemic in NYC, there was a significant increase in the proportion of penetrating mechanisms. Less-injured non-COVID patients experienced an increase in mortality in the early pandemic, possibly from a depletion of human and hospital resources from the large influx of COVID patients. These data lend support to the safeguarding of trauma system resources in the event of a future pandemic. Prognostic and Epidemiologic; Level III.

Public Health Detailing to Promote HIV Pre- and Postexposure Prophylaxis Among Women's Healthcare Providers in New York City

Equitable access to HIV pre- and postexposure prophylaxis for women is essential to ending the HIV epidemic. Providers' lack of knowledge and comfort in discussing and prescribing pre-exposure prophylaxis to women persist as barriers. From May to November 2019, the New York City Health Department conducted its first public health detailing campaigns among women's healthcare providers to promote pre- and postexposure prophylaxis and the associated best practices. Over 2 campaigns (10 weeks each), trained Health Department representatives visited providers for 1-on-1 visits at select practices to promote key messages. Representatives distributed an Action Kit that addressed knowledge gaps and practice needs on providing pre-exposure prophylaxis and postexposure prophylaxis to cisgender and transgender women. Providers completed an assessment at the beginning of initial and follow-up visits, used to compare responses across visits. Statistically significant changes were evaluated by generalized linear models of bivariate outcomes, adjusted for nonindependence of providers at the same practice. Representatives visited 1,348 providers specializing in primary care (47%), women's health (30%), adolescent health (7%), infectious disease (4%), and other (12%) at 860 sites; 1,097 providers received initial and follow-up visits. Provider report of ever prescribing pre-exposure prophylaxis increased by 12% (n=119 providers); increases were reported in measures of taking sexual history, asking about partners' HIV status, providing postexposure prophylaxis, recognizing pre-exposure prophylaxis's effectiveness, and discussing and referring for pre-exposure prophylaxis. After public health detailing, women's healthcare providers report increased adoption of recommended practices that promote pre- and postexposure prophylaxis uptake and sexual wellness among women. Detailing may be adaptable to other regions and contexts to reach providers.

Albumin as a Prognostic Indicator in Pre-Intubated Patients With SARS-CoV-2: A Retrospective, Multi-Institutional Study.

BackgroundMuch effort has been placed on evaluating serological tests that can predict worsening prognosis in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Endotracheal intubation in SARS-CoV-2 is associated with a higher risk of mortality. While studies have evaluated serological markers that can predict worsening prognosis, the likelihood of intubation in these patients has not been evaluated. The objective of this study was to determine if any serum marker corresponded to oxygen escalation or de-escalation in SARS-CoV-2-infected pre-intubated patients.MethodologyThis retrospective study reviewed 1,754 SARS-CoV-2 patients in the New York City Health and Hospitals Corporation (NYCHHC) system who required non-invasive positive pressure ventilation (NIPPV) such as continuous positive airway pressure or bilevel positive airway pressure. All patients were above the age of 18, were not terminally ill and requiring hospice care, and were admitted to the NYCHHC system between March 1, 2020 and May 17, 2020. SARS-CoV-2 serological labs were collected for five days for patients initiated on NIPPV, such that day one was 24 hours after NIPPV initiation.ResultsMultivariate and univariate linear regression modeling on this population cohort was remarkable for a significant association between serum albumin levels and oxygen escalation or de-escalation from NIPPV.ConclusionsWe conclude that serum albumin level may have further utility in predicting oxygen escalation in pre-intubated patients with SARS-CoV-2, especially in a low-resource and high-demand setting.

PrEP Use and Correlates of Use Among a Large, Urban Sample of Men and Transgender Persons Who Have Sex with Men.

We examined recent pre-exposure prophylaxis (PrEP) use (past 6months) and its correlates among a large sample of men who have sex with men and transgender and gender non-conforming persons participating in a home HIV self-testing program conducted by the New York City Health Department between 11/2016 and 1/2017. Correlates examined included demographic characteristics and HIV-related behaviors in the past 6months. Associations with recent PrEP use were assessed using log-binomial regression. 400 (22.5%) of 1776 participants reported recent PrEP use. In adjusted models, recent PrEP use was associated with Manhattan residence [adjusted prevalence ratio (aPR) 1.26; 95% confidence interval (CI) (1.04, 1.53)], higher income [aPR 1.29; 95% CI (1.03, 1.62)], and having insurance [aPR 1.89; 95% CI (1.33, 2.69)]. All HIV-related behaviors, except for injection drug use, were individually associated with PrEP use. More research is needed to better understand barriers to PrEP use among patients who are low income and/or uninsured as this may help improve current public health efforts to increase PrEP uptake among disproportionately impacted populations.

A NOVEL EVIDENCE-BASED PREDICTOR TOOL FOR HOSPITALIZATION AND LENGTH OF STAY: INSIGHTS FROM PATIENTS WITH COVID-19 IN NEW YORK CITY

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Coronavirus disease 2019 (COVID-19) has infected more than 150 million people worldwide. Predictive models for key outcomes can optimize resource utilization and patient outcome as outbreaks continue. We aimed to design and internally validate a web-based calculator predictive of hospitalization and length of stay (LOS) in a large cohort of COVID-19 positive patients presenting to the Emergency Department (ED) in a New York City health system. METHODS: The study cohort consisted of consecutive adult (>18 years) patients presenting to the ED of one of the Mount Sinai Health System hospitals between March, 2020 and April, 2020 who were diagnosed with COVID-19. Logistic regression was utilized to construct predictive models for hospitalization and prolonged (>3 days) LOS. Discrimination was evaluated using area under the receiver operating curve (AUC). Internal validation with bootstrapping was performed, and a web-based calculator was implemented. RESULTS: From 5859 patients, 65% were hospitalized. Independent predictors of hospitalization included older age (OR=6.29; 95% CI [1.83-2.63], >65 vs. 18-44), male sex (OR=1.35 [1.17-1.55]), chronic obstructive pulmonary disease (OR=1.74; [1.00-3.03]), hypertension (OR=1.39; [1.13-1.70]), diabetes (OR=1.45; [1.16-1.81]), chronic kidney disease (OR=1.69; [1.23-2.32]), elevated maximum temperature (OR=4.98; [4.28-5.79]), and low minimum oxygen saturation (OR=13.40; [10.59-16.96]). The mean LOS was 7.3 days (SD=5.3 days; median=6 days; IQR=6 days). Predictors of extended LOS included older age (OR=1.03 [1.02-1.04], per year), chronic kidney disease (OR=1.91 [1.35-2.71]), elevated maximum temperature (OR=2.91 [2.40-3.53]), and low minimum percent oxygen saturation (OR=3.89 [3.16-4.79]). AUCs of 0.881 and 0.770 were achieved for hospitalization and LOS, respectively. Elevated levels of CRP, creatinine, and ferritin were key determinants of hospitalization and LOS (p<0.05). A calculator was made available under the following URL: https://covid19-outcome-prediction.shinyapps.io/COVID19_Hospitalization_Calculator/ CONCLUSIONS: This study yielded internally validated models with good discrimination that predict both the need for hospitalization in COVID-19 patients presenting to the ED, and the risk of prolonged hospitalization among admitted patients. Older age, chronic kidney disease, fever, and oxygen desaturation predicted the need of hospitalization and extended LOS. Additional predictors for hospitalization included male gender, chronic obstructive pulmonary disease, hypertension, and diabetes. CLINICAL IMPLICATIONS: We developed a practical tool predicting hospitalization risk in patients presenting to the ED diagnosed with COVID-19. This tool can be used to optimize resource allocation, help guide quality of care, and assist in designing future studies on the triage and management of patients with COVID-19. DISCLOSURES: No relevant relationships by Jeeyune Bahk, source=Web Response No relevant relationships by Maan El Halabi, source=Web Response No relevant relationships by James Feghali, source=Web Response No relevant relationships by Kam Sing Ho, source=Web Response No relevant relationships by Judy Huang, source=Web Response No relevant relationships by Joseph Mathew, source=Web Response no disclosure on file for Bharat Narasimhan; No relevant relationships by Georgina Osorio, source=Web Response No relevant relationships by David Steiger, source=Web Response No relevant relationships by Paulino Tallón de Lara, source=Admin input No relevant relationships by Juan Wisnivesky, source=Web Response

POST-ACUTE COVID-19 SYNDROME AND DIGITAL NECROSIS: A VIRAL SEQUELAE

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coronavirus disease 2019 (COVID-19) undoubtedly produces a hypercoagulable state. Even though the pathogenesis of this phenomenon is incompletely understood, the extensive endothelial injury and elevated prothrombotic microparticles can produce clinical manifestations ranging from asymptomatic microthrombosis to death [1]. Moreover, the chronic stasis a demented and institutionalized patient has, exponentially increases the risk of embolization. CASE PRESENTATION: An 88-year-old woman with past medical history of Alzheimer's dementia, schizophrenia, paroxysmal atrial fibrillation and COVID-19 pneumonia one month prior, presented from a nursing home complaining of right hand pain. Physical examination revealed a right hand with necrosis on the tip of all five fingers and nail avulsion in the fifth digit (Figure 1, 2). The patient's apixaban had been recently discontinued due to a gastrointestinal bleed. Upon further review, no recent trauma, radiation or procedures on the right arm were noted. Initial work-up was remarkable for elevated fibrinogen activity and a D-dimer of 3350 ng/ml (reference range: less than 500). Antinuclear antibody (ANA) was positive but prothrombin time, activated partial thromboplastin time, international normalized ratio, rheumatoid factor, antineutrophil cytoplasmic antibody (ANCA), p-ANCA, C3 and C4 were within normal limits. An electrocardiogram and continuous telemetry monitoring showed normal sinus rhythm. Right hand x-ray revealed digital soft tissue swelling of the first, second and fifth digits on the right hand with no evidence of fracture (Figure 3). Ultrasound of the right upper extremity showed a non-compressible occlusive thrombus in the right cephalic vein. She was started on antibiotics while Orthopedic surgery performed partial amputation of the first and second right hand digits with debridement of the remaining fingers. Apixaban was restarted and she made a full recovery thereafter. DISCUSSION: COVID-19's dysregulated immune response inevitably leads to microvascular inflammation and cell injury. These phenomenons, in conjunction with chronic immobilization, produce a critical risk for a hypercoagulable state [1]. Furthermore, emergent research has elucidated an extensive array of manifestations in the mediate course of this viral infection. Multivariate analyses have demonstrated how the rate of venous thromboembolism in the post-acute COVID-19 patients can be up to 5% with a median of 23 days post discharge [2]. Moreover, a positive ANA without an underlying immunological disease has been described in patients with COVID-19 [3]. CONCLUSIONS: Digital necrosis should be included in potential post-COVID-19 complications and patients with high thrombosis risk must be considered for prophylactic anticoagulation. Further research is warranted to establish the potential risk-benefit relationship of treatment and the most appropriate time of prophylaxis. REFERENCE #1: Bilaloglu S, Aphinyanaphongs Y, Jones S, Iturrate E, Hochman J, Berger JS. Thrombosis in Hospitalized Patients With COVID-19 in a New York City Health System. JAMA. 2020;324(8):799. doi:10.1001/jama.2020.13372 REFERENCE #2: Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nature Medicine. 2021;27(4):601-615. doi:10.1038/s41591-021-01283-z REFERENCE #3: Lerma LA, Chaudhary A, Bryan A, Morishima C, Wener MH, Fink SL. Prevalence of autoantibody responses in acute coronavirus disease 2019 (COVID-19). Journal of Translational Autoimmunity. 2020;3:100073. doi:10.1016/j.jtauto.2020.100073 DISCLOSURES: No relevant relationships by Abdul Rahman Al Armashi, source=Web Response No relevant relationships by Faris Hammad, source=Web Response No relevant relationships by Keyvan Ravakhah, source=Web Response No relevant relationships by Francisco Somoza-Cano, source=Web Response

ACUTE LIMB ISCHEMIA IN A YOUNG ADULT WITH COVID-19 INFECTION

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: COVID-19 infection is now well known to cause venous thrombotic complications. More recently, arterial thrombotic complications of COVID-19 have been reported. Incidence of Acute limb ischemia (ALI) ranges from 3 to 15%. CASE PRESENTATION: A 50-year-old male with a history of hypertension presented to the ED with left foot numbness, discoloration, and pain for 2 days. Two weeks before the presentation, he tested positive for SARS-CoV2 after an outpatient evaluation for acute cough. He did not have any other respiratory complaints and was quarantined at home. His cough persisted, but he denied any fever, shortness of breath, chest pain, or hemoptysis. On physical exam, he was afebrile, heart rate of 71 beats per minute, blood pressure 141/90 mm of Hg, respiratory rate of 19 breaths per minute, and oxygen saturation of 98% while breathing ambient air. His respiratory exam was unremarkable. There were no palpable femoral, popliteal, dorsalis pedis, and posterior tibial pulses on the left side. He had sensory loss in the left foot. Laboratory evaluation showed mild transaminitis. His CK was 767 U/L, and D-dimer was 4.92 mg/L. CTA abdominal aorta with iliofemoral runoff was performed, which showed partial occlusion of the distal abdominal aorta, near-complete occlusion of the left common iliac artery, and complete occlusion of the proximal popliteal artery at the level of the distal femur with no flow distal to this point.Anticoagulation with unfractionated heparin was initiated. The patient was emergently taken to the OR and underwent extensive embolectomy involving the aortoiliac, femoral, popliteal, and tibial artery of the left leg. Antiphospholipid antibodies were normal. He had no family or personal history of blood clots. His presentation was believed to be due to thrombotic complications of the COVID-19 infection. His postoperative course was unremarkable, and he was discharged home on postoperative day 5. DISCUSSION: ALI is a vascular emergency. The exact pathophysiology causing thrombosis is unknown, but endothelial dysfunction, cytokine production, acquired antiphospholipid syndrome, and hypoxia may contribute to thrombosis (1). The current prevalence of ALI is noted to be 4 to 21 per 100,000 COVID-19 hospitalizations. In one observational review and in most case series, the median age was over 60. Male sex, Hispanic ethnicity, history of myocardial infarction, CAD, and elevated D-dimer increase the risk of developing ALI (2). The patient usually presents with pain, pallor, numbness, and loss of pulses. CONCLUSIONS: We present a young patient with no significant risk factors and otherwise mild COVID-19 infection presenting with acute lower limb ischemia. A high index of suspicion and prompt recognition of ALI in patients with COVID-19 infection is critical. Surgical revascularization, either open or catheter-directed, and systemic anticoagulation is the mainstay of treatment. REFERENCE #1: Rahi MS, Jindal V, Reyes S-P, Gunasekaran K, Gupta R, Jaiyesimi I. Hematologic disorders associated with COVID-19: a review. Annals of Hematology. 2021. REFERENCE #2: Bilaloglu S, Aphinyanaphongs Y, Jones S, Iturrate E, Hochman J, Berger JS. Thrombosis in Hospitalized Patients With COVID-19 in a New York City Health System. Jama. 2020. DISCLOSURES: No relevant relationships by Kwesi Amoah, source=Web Response No relevant relationships by Kavitha Gopalratnam, source=Web Response No relevant relationships by Kulothungan Gunasekaran, source=Web Response No relevant relationships by Lakshmi Polisetty, source=Web Response No relevant relationships by Mandeep Singh Rahi, source=Web Response