York Hospital Research Articles

Characterization of Listeria monocytogenes isolated from wildlife in central New York.

Background Listeria monocytogenes (Lm) present in farming soil and food‐processing facilities threatens food safety, but little is known about the carriage of Lm by wildlife.ObjectivesWe estimated the prevalence of faecal Lm shedding among wildlife admitted to a veterinary medical teaching hospital in central New York and characterized a subset of the Lm isolates.MethodsWildlife samples were collected between May 2018 and December 2019. We characterized the Lm isolates by assessing the growth at three temperatures approximating the body temperatures of reptiles (25°C), mammals (37°C), and birds (42°C) and identifying genotypic characteristics related to transmission and virulence.ResultsThe apparent prevalence of faecal Lm shedding was 5.6% [18/324; 95% confidence interval (CI), 3.3%–8.6%]. Among 13 isolates that represented two lineages and 11 clonal complexes, three and five isolates were grouped into the same SNP clusters with human clinical isolates and environmental isolates, respectively. However, specific SNP difference data showed that Lm from wildlife was generally not closely related (>22 SNP differences) to Lm from human clinical sources and the food‐processing environment. While the stress response locus SSI‐2 was absent, SSI‐1 was found in four isolates. Virulence genes prfA, plcA, hly, mpl, actA, plcB, inlA, inlB, inlC, inlE, inlH, inlJ, and inlK were present, without any premature stop codons, in all isolates. Virulence loci Listeria pathogenicity island 3 (LIPI‐3) and LIPI‐4, which have been linked to hypervirulence, and inlG were found in four, three, and seven isolates, respectively.ConclusionsWildlife represents a potential reservoir for genetically diverse and putatively hypervirulent Lm strains. No statistically significant association between growth parameters and hosts was observed. However, compared to lineage I isolates, lineage II isolates showed significantly (p < 0.05) faster growth at 25°C and significantly slower growth at 42°C, suggesting that wildlife Lm isolates that belong to lineages I and II differ in their ability to grow at 25°C and 42°C.

Abstract WP198: Hematological And Embolic Biomarkers And Clinical Outcomes In Patients With Cancer And Ischemic Stroke

Introduction: We previously showed that patients with cancer and acute ischemic stroke (AIS) have higher markers of coagulation, platelet, and endothelial activation, and more circulating microemboli than patients with AIS and no cancer. Herein, we evaluate whether these markers are associated with clinical outcomes in patients with cancer and AIS. Methods: In the MOST-Cancer prospective study, we enrolled 50 adults with active solid-tumor cancer and AIS at 2 New York hospitals from 2016-2020. We collected blood from participants 72-120 hours after stroke onset. We performed a 30-minute transcranial Doppler (TCD) microemboli detection study a median of 4 days after stroke onset. The exposure variables were hematological markers of coagulation (D-dimer, thrombin-antithrombin), platelet (P-selectin), and endothelial activation (thrombomodulin, soluble intercellular adhesion molecule-1 [sICAM-1], soluble vascular cell adhesion molecule-1 [sVCAM-1]), and the presence of microemboli on TCD. The primary outcome was a composite of recurrent arterial or venous thromboembolism or death. The secondary outcome was recurrent AIS. We used Cox regression to evaluate individual associations between biomarkers and subsequent outcomes. Results: Median age was 69 years (IQR, 60-76) and 24 participants (48%) were women. The most common cancers were lung (28%) and pancreatic (22%); 86% of participants had distant metastases. During a mean follow-up of 278 days (SD, 367), 43 (86%) participants had the primary outcome of recurrent thromboembolism or death, including 28 (56%) who had recurrent thromboembolism, 13 who had recurrent AIS (26%), and 30 (60%) who died. D-dimer, P-selectin, sICAM-1, sVCAM-1, and microemboli were associated with the composite outcome (Table). Similar results were seen for recurrent AIS. Conclusion: Markers of hypercoagulability and embolic disease were associated with adverse clinical outcomes in cancer-related stroke.

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.

Measurement of the cardiac time intervals of the fetal ECG utilising a computerised algorithm: A retrospective observational study.

ObjectiveEstablish whether the reliable measurement of cardiac time intervals of the fetal ECG can be automated and to address whether this approach could be used to investigate large datasets.DesignRetrospective observational study.SettingTeaching hospitals in London UK, Nottingham UK and New York USA.ParticipantsSingleton pregnancies with no known fetal abnormality.MethodsArchived fetal ECG's performed using the MonicaAN24 monitor. A single ECG (PQRST) complex was generated from 5000 signal-averaged beats and electrical cardiac time intervals measured in an automated way and manually.Main Outcome measureValidation of a newly developed algorithm to measure the cardiac time intervals of the fetal ECG.Results188/236 (79.7%) subjects with fECGs of suitable signal:noise ratio were included for analysis comparing manual with automated measurement. PR interval was measured in 173/188 (92%), QRS complex in 170/188 (90%) and QT interval in 123/188 (65.4%). PR interval was 107.6 (12.07) ms [mean(SD)] manual vs 109.11 (14.7) ms algorithm. QRS duration was 54.72(6.35) ms manual vs 58.34(5.73) ms algorithm. QT-interval was 268.93 (21.59) ms manual vs 261.63 (36.16) ms algorithm. QTc was 407.5(32.71) ms manual vs 396.4 (54.78) ms algorithm. The QRS-duration increased with gestational age in both manual and algorithm measurements.ConclusionAccurate measurement of fetal ECG cardiac time intervals can be automated with potential application to interpretation of larger datasets.

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.

Discriminating Multisystem Inflammatory Syndrome in Children Requiring Treatment From Common Febrile Conditions in Outpatient Settings

To identify specific symptoms, physical examination findings, and laboratory findings that are more indicative of patients with multisystem inflammatory syndrome in children (MIS-C), as opposed to other febrile illnesses.Two cohorts of patients ≥12 months were used in this study. Included in the first cohort were 44 patients who were diagnosed and treated for MIS-C at a large urban children’s hospital in New York. Included in the second cohort were 181 patients who presented for evaluation of a febrile illness to a hospital-affiliated primary care pediatric clinic, 23 of whom were also evaluated in the emergency department.This study was performed via a retrospective chart review. The inpatient cohort was selected from the New York City Department of Health’s list of possible MIS-C cases from April 16 to June 10, 2020. Patients with MIS-C were defined as those who received treatment with intravenous immunoglobulin and corticosteroids in concordance with recommendations by rheumatology and infectious disease specialists. Patients whose cases were more consistent with Kawasaki disease as per American Heart Association 2017 guidelines and clinical judgement were excluded. Outpatient cases were selected by using a list of all patients who presented for an acute febrile illness during the same time period. Fever was defined as a temperature ≥38°C, but, if not documented or if <38°C, the fever height was recorded as “subjective.” Because most outpatients were evaluated via telehealth, laboratory testing was compared only between inpatients and patients evaluated in the emergency department. Demographics, laboratory values, physical examination findings, and symptoms were compared among the 2 groups.Patients diagnosed with MIS-C, compared with those diagnosed with other febrile illnesses were found to exhibit the following: greater median age (8.2 years versus 3.5 years; P < .001), greater maximum temperature (40.0°C vs 38.9°C; P < .001), and longer duration of fever before presentation (5 days versus 2 days; P < .001). Laboratory evaluation among patients with MIS-C versus those who presented to the ED for fever revealed more significant lymphopenia (absolute lymphocyte count: 900 cells per µL [490–1700] vs 2860 cells per µL [1900–5400], respectively; P < .001), a greater neutrophil percentage (80.5% [71.6–85.7] vs 40.1% [19–60]; P < .001), and a lower initial platelet count (179 000 per µL [130 000–243 000] vs 224 000 per µL [195 000–308 000]; P < .05). Patients with MIS-C were also found to have statistically significant elevated levels of C-reactive protein (164 mg/L [52–250]) and N-terminal brain natriuretic peptide (6700 pg/µL [2509–25 550]), but these values were only available in 14 inpatients and 9 outpatients. Clinical symptoms, including abdominal pain, vomiting, mucosal irritation, neck pain or stiffness, and rash, all correlated with MIS-C (P < .05)In comparing patients with MIS-C to patients with other febrile illnesses, a particular set of symptoms, laboratory values, and physical findings were identified.The diagnosis and management of MIS-C has evolved over the course of the pandemic, and the clinical presentation can be variable. With this study, the authors help to highlight clinical findings in patients with a diagnosis more consistent with MIS-C, as opposed to other febrile illnesses. When evaluating patients with fever, it is important to be aware of these possible MIS-C “red flags” but equally important to have a broad differential diagnosis. Appropriately diagnosing patients with MIS-C is imperative because current treatment recommendations include immunomodulation with corticosteroids and immunoglobulin. Such treatment may be undesirable in patients with overlap symptoms secondary to other systemic diseases (ie, sepsis or malignancy).

Virtual visits to optimize research trial offerings to heart failure patients

BackgroundClinical trials are crucial for development of new treatments that impact outcomes. Assessments used in heart failure trials include the 6-minute hallway walk test (6MWT) and timed up and go test (TUG).ObjectivesWe hypothesized that 6MWT and TUG performed virtually would be feasible and comparable to in-person functionality testing for heart failure patients.MethodsThis pilot study explored the use of virtual visits to collect functional information on patients living with heart failure. Patients were enrolled in an outpatient setting. Informed consent was obtained. Baseline testing consisted of patient-reported New York Hospital Association class, quality-of-life surveys (EQ-5D-5L, Kansas City Cardiomyopathy Questionnaire [KCCQ], Frailty Index for Elders), and cognitive assessments (Mini-Cog). Patients also completed an in-person TUG and 6MWT at baseline. Patients were issued supplies to set up TUG/6MWT courses at home. Follow-up video visits occurred 7 days and 14 days (± 3 days) postbaseline. Surveys (EQ-5D-5L, KCCQ, Frailty Index), TUG, and 6MWT were completed. Study staff reviewed 6MWT/TUG course set-up for accuracy and supervised patients during testing.ResultsOf the 94 patients enrolled, 74 patients completed all 6MWT assessments. One-way repeated measures ANOVA found no statistical difference between mean in-person and virtual 6MWT (P = .45). One-way repeated measures ANOVA found a statistical difference between mean TUG scores (P = .03). Patients were comfortable with the use of virtual visits (56%), would participate in research studies through telemedicine (98.7%), and found completing a virtual research visit to be not difficult (77.3%).ConclusionVirtual administration of the 6MWT was shown to be feasible and acceptable to heart failure patients as compared to in-person functionality testing. This approach could be implemented into clinical care pathways for evaluation of heart failure patients, as well as adopted by industry-sponsored and investigator-initiated research studies in heart failure cohorts for data collection.

Nasal skin reconstruction: Time to rethink the reconstructive ladder?

BackgroundNasal scarring can compromise aesthetics and function given its complex three-dimensional structure and central location. This study aimed to measure patients’ satisfaction after reconstruction for nasal defects following Mohs micrographic surgery. MethodsPatients presenting with nasal nonmelanoma skin cancer at Memorial Sloan Kettering Cancer Center New York, USA and Catharina Hospital Eindhoven, Netherlands from April 2017 to November 2019 were asked to participate. Reconstruction type, complications, and patients satisfaction were assessed. Patients completed the FACE-Q Skin Cancer – Satisfaction with Facial Appearance scale (preoperative and 1-year postoperative) and the Appraisal of Scars scale (1-year postoperative). ResultsA total of 128 patients completed the preand postoperative scales. There were 35 (27%) surgical defects repaired with primary closures, 71 (55.5%) with flaps, and 22 (17.2%) with full-thickness skin grafts (FTSG). Patients that underwent a flap or FTSG reconstruction had higher scar satisfaction scores than primary closures (p = 0.03). A trend was seen with patients following flap reconstructions scoring 7.8 points higher than primary closures and patients with upper nose defects scoring 6.4 points higher than lower nose defects. Males were significantly more satisfied than females. No significant difference was observed in the preoperative and postoperative facial appearance scores between the three groups (p = 0.39). ConclusionPatients are more satisfied in the long term with their scars after flap reconstructions compared to primary closures. Therefore, nasal skin reconstruction may not follow the traditional reconstructive ladder and more complex approaches may lead to higher long-term scar satisfaction.

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.

EP.TU.141A 5-year Post Colonoscopy Colorectal Cancer audit with focus on root cause analysis and performance at York Teaching Hospital

Abstract Introduction Post colonoscopy colorectal cancer (PC-CRC) is an important benchmark of endoscopy performance. Previous publications have reported significant variations between institutions. We chose to perform the root cause analysis (RCA) and the impact of traditional performance indicators on the likelihood of PC-CRC. Methods A retrospective analysis was performed on all PCCRC at York Hospital. Electronic endoscopic records and case-note review was performed to identify appropriate cases. Root cause analysis was performed on all identified cases. Performance data and annual procedural volumes of endoscopist were recorded. Adjusted PC-CRC/5-year period allowed endoscopist to be divided into good (&amp;lt;4 PC-CRC) and poor performers (³4 PC-CRC). Mann Whitney U test used to compare groups. P-value of &amp;lt; 0.05 deemed significant Results 32 (24 male) patients with a PC-CRC were identified . Median age was 72 (IQR 63-79) years. Table provides PCCRC rate for the 5-year period. Root cause analysis identified that most plausible cause was missed lesions despite adequate bowel preparation (76%). The commonest subtype was non interval C (38%). Three out of 18 endoscopist had a higher 5-year adjusted PC-CRC rate and were poor performers. Median withdrawal times, CIR and ADR did not differ between good and poor performers. Conclusion The overall PC-CRC rate at our institution is within an acceptable rate. We have noted significant variation of performance between endoscopist, the exact reasons for this observation require further examination.

Breast Cancer Survivorship Care During the COVID-19 Pandemic Within an Urban New York Hospital System

Purpose/Objective(s)The COVID-19 pandemic has placed a tremendous burden on healthcare systems and has forced oncology providers and cancer patients to balance pandemic risks with maintaining standard cancer survivorship care. We evaluated adherence to long-term follow-up among early-stage breast cancer patients in an urban, academic cancer center in the New York City borough of The Bronx during the COVID-19 pandemic.Materials/MethodsWe retrospectively reviewed patients with stage I-II breast cancer who underwent resection and adjuvant therapy at our center. Adherence with long-term follow-up was evaluated based on contact with any oncology specialist (surgical, medical, or radiation) at our center between two and five years after breast cancer surgery. Patients were deemed adherent to follow-up during COVID-19 if they attended an oncology follow-up appointment (in-person or telemedicine) between March 1 and December 1, 2020; patients were deemed non-adherent if they attended follow-up during the same date range in 2019, prior to the pandemic, but did not follow-up during the COVID-19 period. Adherence during COVID-19 was compared with pre-COVID rates of follow-up. Clinical and demographic data were evaluated as potential predictors of adherence. Local COVID-19 case rates were estimated from public data by ZIP code during the peak of the pandemic in April 2020. Multivariate logistic regression was performed to identify associations with follow-up non-adherence.ResultsDuring COVID-19, 496 (68%) of 734 patients were adherent to follow-up. Of the adherent group, 40.5% had telemedicine visits. The rate of follow-up adherence during COVID-19 was dramatically lower than historic adherence rates of 89-96%, which varied depending on time since resection. On multivariate analysis, adherence was more likely among patients who had received adjuvant radiation therapy (adjusted Odds Ratio [aOR] 1.4; P = 0.032) and smokers (aOR 1.6; P = 0.041). When patients who live in The Bronx were stratified by ZIP code, there was no association (R2 = 0.01) between local COVID-19 case rates and likelihood of adherence during the COVID-19 pandemic.ConclusionTo our knowledge, this is the first analysis evaluating the potential effect of COVID-19 on cancer survivorship care. We observed a dramatic disruption in long-term follow-up during the COVID-19 period, despite prevalent utilization of telemedicine visits. Overall, if the observed rate of non-adherence persists and patients are not reintegrated into regular follow-up patterns after the COVID-19 period, it has the potential to dramatically affect cancer survival outcomes.

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.

MULTIPLE ORGAN SYSTEMS INVOLVEMENT IN COVID-19 IS ASSOCIATED WITH INCREASED IN MORTALITY

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Coronavirus disease 2019 (COVID-19) has multiple organ system involvement but the association of organ systems involvement with mortality has not been reported. We study the association of organ systems involved with mortality in COVID-19. METHODS: Retrospective study of 808 consecutive patients with confirmed-laboratory diagnosis of COVID-19 in a New York hospital from March 1 - May 15, 2020. We investigated involvement of eight organ systems: respiratory, neurologic, renal, cardiovascular, liver, endocrine, musculoskeletal, and hematologic. Respiratory was nadir oxygen saturation 0.3mg/dL or 1.5-fold increase from baseline. Cardiovascular was any new troponin elevation >0.04ng/mL, new onset of HF, acute on chronic HF, new or worsening of atrial fibrillation, supraventricular tachycardia, new AV block, new ventricular tachycardia, new inotrope use, or new vasopressor use. Liver was serum alanine aminotransferase more than 1.5 times normal limit (>60IU/L) or abnormal total serum bilirubin >1.1mg/dL. Endocrine was any blood glucose level 140 mg/dL, or any new or higher (from baseline) insulin administration requirement. Musculoskeletal was any creatine kinase values >1,000 units/L. Hematologic was involvement of any one cell line: white blood cell count <4×10

P10.08 Comparing Lung Cancer in Never Smokers and Ever Smokers in Asian or Asian American Patients Treated at a Tertiary Urban Public Hospital in New York

The higher incidence of targetable mutations in Asian patients with lung cancer clearly suggests potentially different risk factors and underlying biology. Most of the studies regarding lung cancer in Asian patients were conducted in Asia, but limited data is known about Asian or Asian American patients in the U.S. While current lung cancer screening guidelines only affect smoker populations, expanding screening to other high risk populations is of interest. The purpose of this study is to assess various characteristics of Asian or Asian American lung cancer patients at a public hospital in New York.

2 Training Emergency Physicians for Mass Casualty Triage during Mass Shooting Events: A New York City- based Pilot Curriculum

Recent literature suggests that emergency departments may be underprepared for the influx of “self-referred” patients following a mass shooting event. Following the mass shootings in Orlando and Las Vegas, the Greater New York Hospital Association determined there was a need to increase the preparation of emergency department clinicians for these events in New York. Through a partnership with the Center for Disaster Medicine at New York Medical College an 8-hour, innovative physician-oriented education program was created and piloted at 5 hospitals using a combination of didactics, table-top exercises, live ultrasound scanning, and in-situ high-fidelity simulation. The results of these pilot course deliveries were used to standardized course curricula available to all New York-area hospitals and identify additional educational needs for physicians and other emergency department staff. Didactic content was created using lessons-learned reports, comprehensive literature reviews, and consultation with physician subject matter experts in the area of trauma surgery, disaster medicine, and emergency ultrasound. Hands-on training was created based on lessons-learned consisted of three afternoon break-out sessions including a hospital-specific bed status management exercise to simulate decompressing the ED and critical care units in advance of the arrival of mass casualties, an immersive ED in-situ mass casualty management scenario utilizing high-fidelity trauma simulators and standardized patient actors, and a breakout session on innovative applications of point-of-care ultrasound for triage and clinical decision making using live standardized patients for scanning. Post-course surveys were distributed to participants and survey items aggregated for analysis and curriculum improvement and revision. Didactic content areas showed universal improvement among all pilot sites using Likert confidence scales to evaluate pre-course vs post-course provider self-efficacy. Practical skills and psychomotor evaluations also showed universal improvement following skills practice consistent with current emergency medicine educational literature. Gaps in the pilot course content reported by participants varied by facility but included wanting similar educational content available for non-physician ED clinicians, and wanting to include non-ED physicians, who might “float” to the ED during a mass casualty, to be included in the training. Additionally, physicians at some hospitals had better mastery of POCUS than others. A suggestion was to offer a stand-alone 4-hour course on emergency ultrasound for hospitals who would like to offer this to their ED physicians. Emergency physicians are the leaders of the hospital response to a mass casualty as the primary clinicians responsible for the triage and treatment of victims from out-of-hospital events. Nevertheless, many emergency physicians report not having the opportunity to receive education on new trends and innovations in mass casualty management, which could make them more effective when responding to a disaster. Departments should consider how they might enrich existing preparedness-related CME and leverage their resources in high-fidelity simulation and ultrasound to offer opportunities to practice skills and techniques that are not often utilized during annual in-service training.

Assessment of Costs and Care Quality Associated With Major Surgical Procedures After Implementation of Maryland’s Capitated Budget Model

In 2014, Maryland implemented the all-payer model, a distinct hospital funding policy that applied caps on annual hospital expenditures and mandated reductions in avoidable complications. Expansion of this model to other states is currently being considered; therefore, it is important to evaluate whether Maryland's all-payer model is achieving the desired goals among surgical patients, who are an at-risk population for most potentially preventable complications. To examine the association between the implementation of Maryland's all-payer model and the incidence of avoidable complications and resource use among adult surgical patients. This comparative effectiveness study used hospital discharge records from the Healthcare Cost and Utilization Project state inpatient databases to conduct a difference-in-differences analysis comparing the incidence of avoidable complications and the intensity of health resource use before and after implementation of the all-payer model in Maryland. The analytical sample included 2 983 411 adult patients who received coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), spinal fusion, hip or knee arthroplasty, hysterectomy, or cesarean delivery between January 1, 2008, and December 31, 2016, at acute care hospitals in Maryland (intervention state) and New York, New Jersey, and Rhode Island (control states). Data analysis was conducted from July 2019 to July 2021. All-payer model. Complications (infectious, cardiovascular, respiratory, kidney, coagulation, and wound) and health resource use (ie, hospital charges). Of 2 983 411 total patients in the analytical sample, 525 262 patients were from Maryland and 2 458 149 were from control states. Across Maryland and the control states, there were statistically significant but not clinically relevant differences in the preintervention period with regard to patient age (mean [SD], 49.7 [19.0] years vs 48.9 [19.3] years, respectively; P < .001), sex (22.7% male vs 21.4% male; P < .001), and race (0.3% vs 0.4% American Indian, 2.8% vs 4.5% Asian or Pacific Islander, 25.9% vs 12.7% Black, 4.7% vs 11.9% Hispanic, and 63.5% vs 63.4% White; P < .001). After implementation of the all-payer model in Maryland, significantly lower rates of avoidable complications were found among patients who underwent CABG (-11.3%; 95% CI, -13.8% to -8.7%; P < .001), CEA (-1.6%; 95% CI, -2.9% to -0.3%; P = .02), hip arthroplasty (-0.8%; 95% CI, -1.0% to -0.5%; P < .001), knee arthroplasty (-0.4%; 95% CI, -0.7% to -0.1%; P = .01), and cesarean delivery (-1.0%; 95% CI, -1.3% to -0.7%; P < .001). In addition, there were significantly lower increases in index hospital costs in Maryland among patients who underwent CABG (-$6236; 95% CI, -$7320 to -$5151; P < .001), CEA (-$730; 95% CI, -$1367 to -$94; P = .03), spinal fusion (-$3253; 95% CI, -$3879 to -$2627; P < .001), hip arthroplasty (-$328; 95% CI, -$634 to -$21; P = .04), knee arthroplasty (-$415; 95% CI, -$643 to -$187; P < .001), cesarean delivery (-$300; 95% CI, -$380 to -$220; P < .001), and hysterectomy (-$745; 95% CI, -$974 to -$517; P < .001). Significant changes in patient mix consistent with a younger population (eg, a shift toward private/commercial insurance for orthopedic procedures, such as spinal fusion [4.3%; 95% CI, 3.4%-5.2%; P < .001] and knee arthroplasty [1.6%; 95% CI, 1.0%-2.3%; P < .001]) and a lower comorbidity burden across surgical procedures (eg, CABG: -0.7% [95% CI, -0.1% to -0.5%; P < .001]; hip arthroplasty: -3.0% [95% CI, -3.6% to -2.3%; P < .001]) were also observed. In this study, patients who underwent common surgical procedures had significantly fewer avoidable complications and lower hospital costs, as measured against the rate of increase throughout the study, after implementation of the all-payer model in Maryland. These findings may be associated with changes in the patient mix.

Retrospective Analysis of COVID-19 Conversion Rate Among Anesthesiologists in Acute Care Centers.

Brief description of the primary research objectiveAmong healthcare workers, anesthesiologists are regarded as frequently exposed frontline providers in the fight against COVID-19 due to their proximity to patient airways and involvement in aerosolized procedures. As such, the risk of contracting the COVID-19 virus as an occupational hazard is presumed to be higher. To date, in most published studies, all healthcare workers were grouped together, independent of specialty or profession. At the time that this survey was distributed, we did not find any peer-reviewed articles that differentiated COVID-19 infection rates among frontline, such as anesthesiologists vs. non-frontline healthcare workers. This retrospective survey’s primary research objective was to report the rate of COVID-19 infection among anesthesiologists compared to the general population of healthcare workers.MethodologyA survey was sent among anesthesiology attendings and residents in Northern New Jersey and Brooklyn, New York hospitals on duty during the peak pandemic from March 2020 to May 2020. Questions in the survey focused on infection rates and adherence to standards of infection precaution and personal protective equipment (PPE) utilization.Main FindingsThis retrospective study highlights the rate of infection among anesthesiologists as a particularly vulnerable subgroup of frontline residents and physicians, as they are called to duty when emergent airway management is required. In our study, the reported rate of contracting COVID-19 among anesthesiologists was 16.7%. This statistic is higher than the infection rates published by studies by New York State and the CDC.ConclusionThe survey sent to anesthesiologists is useful to understand the impact of COVID-19 on this subgroup of frontline providers and the importance of adhering to standards of infection protocol and the role of PPE.

Breast cancer survivorship care during the COVID-19 pandemic within an urban New York Hospital System

PurposeTo examine clinicodemographic determinants associated with breast cancer survivorship follow-up during COVID-19. MethodsWe performed a retrospective, population-based cohort study including early stage (Stage I-II) breast cancer patients who underwent resection between 2006 and 2018 in a New York City hospital system. The primary outcome was oncologic follow-up prior to and during the COVID-19 pandemic. Secondary analyses compared differences in follow-up by COVID-19 case rates stratified by ZIP code. ResultsA total of 2942 patients with early-stage breast cancer were available for analysis. 1588 (54%) of patients had attended follow-up in the year prior to the COVID-19 period but failed to continue to follow-up during the pandemic, either in-person or via telemedicine. 1242 (42%) patients attended a follow-up appointment during the COVID-19 pandemic.Compared with patients who did not present for follow-up during COVID-19, patients who continued their oncologic follow-up during the pandemic were younger (p = 0.049) more likely to have received adjuvant radiation therapy (p = 0.025), and have lower household income (p = 0.031) on multivariate modeling. When patients who live in Bronx, New York, were stratified by ZIP code, there was a modest negative association (r = −0.56) between COVID-19 cases and proportion of patients who continued to follow-up during the COVID-19 period. ConclusionWe observed a dramatic disruption in routine breast cancer follow-up during the COVID-19 pandemic. Providers and health systems should emphasize reintegrating patients who missed appointments during COVID-19 back into regular surveillance programs to avoid significant morbidity and mortality from missed breast cancer recurrences.

Health Care Workers' Attitudes Toward Patients With COVID-19.

BackgroundEarly in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, before the routine availability and/or use of personal protective equipment, health care workers were understandably concerned. Our aim was to explore health care workers’ attitudes toward patients infected with SARS-CoV-2 at the time of the nation’s first surge in 2 highly affected hospitals in New York.MethodsWe performed a cross-sectional, self-administered survey study of health care workers. The survey consisted of 17 multiple-choice questions including demographic information, ethics, and willingness to care for patients with SARS-CoV-2 infection. Subgroup analyses were performed using the Fisher exact test.ResultsOf 340 health care workers approached, 338 (99.4%) consented to the survey; 163 (48.7%) were registered nurses and 160 (48.3%) lived with children. While 326 (97.3%) workers were concerned about putting their family/coworkers at risk of infection after caring for a patient with SARS-CoV-2, only 30 (8.9%) were unwilling to treat a patient with SARS-CoV-2 infection. Registered nurses were more likely than other health care workers to think it was ethical to refuse care for SARS-CoV-2-infected patients, worried more often about contracting infection, and felt that SARS-CoV-2 added to their stress level (P = .009, P = .018, P < .001, respectively). A similar contrast was seen when comparing workers who live with children with those who did not.ConclusionsLevels of stress and concern were extremely high. In spite of that, the overwhelming majority of workers were willing to treat patients with SARS-CoV-2 infection. Registered nurses and health care workers who live with children were more likely to think it is ethical to refuse care for SARS-CoV-2-infected patients.

Incidence of Respiratory Syncytial Virus Infection Among Hospitalized Adults, 2017-2020.

Respiratory syncytial virus (RSV) causes acute respiratory illness (ARI) and triggers exacerbations of cardiopulmonary disease. Estimates of incidence in hospitalized adults range widely, with few data on incidence in adults with comorbidities that increase the risk of severity. We conducted a prospective, population-based, surveillance study to estimate incidence of RSV hospitalization among adults overall and those with specific comorbidities. Hospitalized adults aged ≥18 years residing in the surveillance area with ≥2 ARI symptoms or exacerbation of underlying cardiopulmonary disease were screened during the 2017-2018, 2018-2019, and 2019-2020 RSV seasons in 3 hospitals in Rochester, New York and New York City. Respiratory specimens were tested for RSV using polymerase chain reaction assays. RSV incidence per 100 000 was adjusted by market share. Active and passive surveillance identified 1099 adults hospitalized with RSV. Annual incidence during 3 seasons ranged from 44.2 to 58.9/100 000. Age-group-specific incidence ranged from 7.7 to 11.9/100 000, 33.5 to 57.5/100 000, and 136.9 to 255.6/100 000 in patients ages 18-49, 50-64, and ≥65 years, respectively. Incidence rates in patients with chronic obstructive pulmonary disease, coronary artery disease, and congestive heart failure were 3-13, 4-7, and 4-33 times, respectively, the incidence in patients without these conditions. We found a high burden of RSV hospitalization in this large prospective study. Notable was the high incidence among older patients and those with cardiac conditions. These data confirm the need for effective vaccines to prevent RSV infection in older and vulnerable adults.