York Metropolitan Region Research Articles

NPCC4: New York City climate risk information 2022-observations and projections.

New York City (NYC) faces many challenges in the coming decades due to climate change and its interactions with social vulnerabilities and uneven urban development patterns and processes. This New York City Panel on Climate Change (NPCC) report contributes to the Panel's mandate to advise the city on climate change and provide timely climate risk information that can inform flexible and equitable adaptation pathways that enhance resilience to climate change. This report presents up-to-date scientific information as well as updated sea level rise projections of record. We also present a new methodology related to climate extremes and describe new methods for developing the next generation of climate projections for the New York metropolitan region. Future work by the Panel should compare the temperature and precipitation projections presented in this report with a subset of models to determine the potential impact and relevance of the "hot model" problem. NPCC4 expects to establish new projections-of-record for precipitation and temperature in 2024 based on this comparison and additional analysis. Nevertheless, the temperature and precipitation projections presented in this report may be useful for NYC stakeholders in the interim as they rely on the newest generation of global climate models.

Humoral and cellular immune responses against SARS-CoV-2 post-vaccination in immunocompetent and immunocompromised cancer populations.

The study was prompted by a desire to better assess the immune status of patients among our cancer host cohort, one of the largest in the New York metropolitan region. Hackensack Meridian Health is the largest healthcare system in New Jersey and cared for more than 75,000 coronavirus disease 2019 patients in its hospitals. The John Theurer Cancer Center sees more than 35,000 new cancer patients a year and performs more than 500 hematopoietic stem cell transplants. As a result, the work was undertaken to assess the effectiveness of vaccination in inducing humoral and cellular responses within this demographic.

Improvement of genetic health and diversity of Zostera marina (eelgrass) in Barnegat Bay, New Jersey ten years after Hurricane Sandy: Support for the “storm stimulus” hypothesis

Hurricane Sandy struck the New York metropolitan region on October 29, 2012. The storm severely impacted the physical state of Barnegat Bay, New Jersey with its heavy storm surge, affecting many forms of benthic life and ripping up extensive beds of Zostera marina. Pre-Sandy studies of the genetic status of Z. marina in Barnegat Bay indicated low levels of heterozygosity and high levels of inbreeding. This present study examines the long-term effects of Hurricane Sandy on the eelgrass meadows of New Jersey. Heterozygosity analysis (mean Ho= 0.482 ± 0.013 and mean He= 0.498± 0.009) of the five Barnegat populations studied suggest an improvement in diversity from pre-Sandy values of 2008. Mean inbreeding levels (overall Fis = 0.077 ± 0.034) also indicated reduced inbreeding, and the fixation index (overall mean pairwise Fst = 0.064 ±0.006) suggested increased connectivity between populations with low levels of differentiation. Although we found no indication of bottlenecks in the last 2–3 years, by employing m-ratio calculations, there was strong evidence for long-term, historical bottlenecks in all populations, potentially due to the mass wasting disease epidemic in the 1930s. Unexpectantly, the post-Sandy genetic health and diversity of Z. marina in Barnegat Bay appears to have improved since it was last surveyed in 2008, supporting the “Storm Stimulus” hypothesis.

Characteristics of Suspected COVID-19 Discharged Emergency Department Patients Who Returned During the First Wave.

Limited information exists on patients with suspected coronavirus disease 2019 (COVID-19) who return to the emergency department (ED) during the first wave. In this study we aimed to identify predictors of ED return within 72 hours for patients with suspected COVID-19. Incorporating data from 14 EDs within an integrated healthcare network in the New York metropolitan region from March 2-April 27, 2020, we analyzed this data on predictors for a return ED visit-including demographics, comorbidities, vital signs, and laboratory results. In total, 18,599 patients were included in the study. The median age was 46 years old [interquartile range 34-58]), 50.74% were female, and 49.26% were male. Overall, 532 (2.86%) returned to the ED within 72 hours, and 95.49% were admitted at the return visit. Of those tested for COVID-19, 59.24% (4704/7941) tested positive. Patients with chief complaints of "fever" or "flu" or a history of diabetes or renal disease were more likely to return at 72 hours. Risk of return increased with persistently abnormal temperature (odds ratio [OR] 2.43, 95% CI 1.8-3.2), respiratory rate (2.17, 95% CI 1.6-3.0), and chest radiograph (OR 2.54, 95% CI 2.0-3.2). Abnormally high neutrophil counts, low platelet counts, high bicarbonate values, and high aspartate aminotransferase levels were associated with a higher rate of return. Risk of return decreased when discharged on antibiotics (OR 0.12, 95% CI 0.0-0.3) or corticosteroids (OR 0.12, 95% CI 0.0-0.9). The low overall return rate of patients during the first COVID-19 wave indicates that physicians' clinical decision-making successfully identified those acceptable for discharge.

Borrelia Infected Neoplastic Glial Cells in Five Patients With Glioblastoma Multiformae

Glioblastoma multiformae (GBM) is a primary malignancy of brain astrocytes. Transcranial stereotactic biopsy specimens from five deceased and anonymous patients with GBM were retrieved from archival storage two years after the death of the patients. All patients were residents of the Long Island, New York metropolitan region where borrelia burgdorferi and borrelia miyamotoi infections are hyperendemic. Fluorescence in situ hybridization (FISH) using two DNA probes specific for genes of burgdorferi borrelia and an additional FISH method study with two DNA probes specific for miyamotoi borrelia each and individually produced high signal borrelia DNA hybridizations inside malignant cells in brain biopsies from all five decedents. Bright signal bacterial DNA hybridizations inside live borrelia spirochetes were found at all levels in serial sections of tumor biopsy fragments in low magnification imaging and outright invasion of the nuclei of individual tumor cells in high resolution imaging. Herein is the first report of a cluster of GBM patients with universal borrelia microbe invasion of neoplastic glial cells.

Older Breast Cancer Survivors: Perspectives on Healthcare Encounters and Unmet Needs

Breast cancer treatment advances have lengthened the survivorship period. Limited attention has focused on the myriad issues breast cancer survivors experience related to their cancer and other health conditions as they age. Focus groups, conducted Fall 2019 – Spring 2020 with a diverse sample of breast cancer survivors from the New York metropolitan region (N=28) explored survivors’ healthcare encounters and goals, quality of life, survivorship lifestyle, other health conditions and risks, e.g. emergence of COVID-19. Participants were 40-82 years old (57% were 56 or older); racially diverse (57% White, 18% Black, 14% Hispanic, 11% Bi-racial); 32% were married/partnered and 57% were parents. Mean diagnosis age was 51. Treatments received included lumpectomy (64%), chemotherapy (57%), radiation (46%), hormonal therapy (39%), and single/bilateral mastectomy (36%). Survivors expressed the importance of restoring normality in their life and the necessity to be pro-active in ensuring their health issues were addressed in medical encounters. Person-centered care and clinician engagement was valued, but not routinely experienced. Survivors evaluated treatment options not just on being cancer-free, but on how it would impact their whole life. They expressed concerns about the future and anxiety over long-term survival. Long term survivors, recipients of early experimental and/or extensive treatments, worried about an emergence of long-delayed adverse health consequences and complications managing other health issues in the future, particularly as they grew older. COVID-19 raised additional health concerns, particularly among those with high risk health conditions due to prior cancer treatments; various self-mandated protective activities were integrated into their self-care practices.

COVID-19 as an Extreme Event in the New York Metropolitan Region

During early 2020, the world encountered an extreme event in the form of a new and deadly disease, COVID-19. Over the next two years, the pandemic brought sickness and death to countries and their cities around the globe. One of the first and initially the hardest hit location was New York City, USA. This article is an introduction to the Special Issue in this journal that highlights the impacts from and responses to COVID-19 as an extreme event in the New York City metropolitan region. We overview the aspects of COVID-19 that make it an important global extreme event, provide brief background to the conditions in the world, and the US before describing the 10 articles in the issue that focus on conditions, events and dynamics in New York City during the initial phases of the pandemic.

Prevalence and Predictors of Venous Thromboembolism or Mortality in Hospitalized COVID-19 Patients.

We aimed to identify the prevalence and predictors of venous thromboembolism (VTE) or mortality in hospitalized coronavirus disease 2019 (COVID-19) patients. A retrospective cohort study of hospitalized adult patients admitted to an integrated health care network in the New York metropolitan region between March 1, 2020 and April 27, 2020. The final analysis included 9,407 patients with an overall VTE rate of 2.9% (2.4% in the medical ward and 4.9% in the intensive care unit [ICU]) and a VTE or mortality rate of 26.1%. Most patients received prophylactic-dose thromboprophylaxis. Multivariable analysis showed significantly reduced VTE or mortality with Black race, history of hypertension, angiotensin converting enzyme/angiotensin receptor blocker use, and initial prophylactic anticoagulation. It also showed significantly increased VTE or mortality with age 60 years or greater, Charlson Comorbidity Index (CCI) of 3 or greater, patients on Medicare, history of heart failure, history of cerebrovascular disease, body mass index greater than 35, steroid use, antirheumatologic medication use, hydroxychloroquine use, maximum D-dimer four times or greater than the upper limit of normal (ULN), ICU level of care, increasing creatinine, and decreasing platelet counts. In our large cohort of hospitalized COVID-19 patients, the overall in-hospital VTE rate was 2.9% (4.9% in the ICU) and a VTE or mortality rate of 26.1%. Key predictors of VTE or mortality included advanced age, increasing CCI, history of cardiovascular disease, ICU level of care, and elevated maximum D-dimer with a cutoff at least four times the ULN. Use of prophylactic-dose anticoagulation but not treatment-dose anticoagulation was associated with reduced VTE or mortality.

Incidence of Venous Thromboembolism and Mortality in Patients with Initial Presentation of COVID-19.

Venous thromboembolism (VTE) has emerged as an important issue in patients with COVID-19. The purpose of this study is to identify the incidence of VTE and mortality in COVID-19 patients initially presenting to a large health system. Our retrospective study included adult patients (excluding patients presenting with obstetric/gynecologic conditions) across a multihospital health system in the New York Metropolitan Region from March 1-April 27, 2020. VTE and mortality rates within 8 h of assessment were described. In 10,871 adults with COVID-19, 118 patients (1.09%) were diagnosed with symptomatic VTE (101 pulmonary embolism, 17 deep vein thrombosis events) and 28 patients (0.26%) died during initial assessment. Among these 146 patients, 64.4% were males, 56.8% were 60 years or older, 15.1% had a BMI > 35, and 11.6% were admitted to the intensive care unit. Comorbidities included hypertension (46.6%), diabetes (24.7%), hyperlipidemia (14.4%), chronic lung disease (12.3%), coronary artery disease (11.0%), and prior VTE (7.5%). Key medications included corticosteroids (22.6%), statins (21.2%), antiplatelets (20.6%), and anticoagulants (20.6%). Highest D-Dimer was greater than six times the upper limit of normal in 51.4%. Statin and antiplatelet use were associated with decreased VTE or mortality (each p < 0.01). In COVID-19 patients who initially presented to a large multihospital health system, the overall symptomatic VTE and mortality rate was over 1.0%. Statin and antiplatelet use were associated with decreased VTE or mortality. The potential benefits of antithrombotics in high risk COVID-19 patients during the pre-hospitalization period deserves study.

The relationship between asthma, eosinophilia, and outcomes in coronavirus disease 2019 infection

BackgroundThe impact of asthma diagnosis and asthma endotype on outcomes from coronavirus disease 2019 (COVID-19) infection remains unclear. ObjectiveTo describe the association between asthma diagnosis and endotype and clinical outcomes among patients diagnosed as having COVID-19 infection. MethodsRetrospective multicenter cohort study of outpatients and inpatients presenting to 6 hospitals in the Mount Sinai Health System New York metropolitan region between March 7, 2020, and June 7, 2020, with COVID-19 infection, with and without a history of asthma. The primary outcome evaluated was in-hospital mortality. Secondary outcomes included hospitalization, intensive care unit admission, mechanical ventilation, and hospital length of stay. The outcomes were compared in patients with or without asthma using a multivariate Cox regression model. The outcomes stratified by blood eosinophilia count were also evaluated. ResultsOf 10,523 patients diagnosed as having COVID-19 infection, 4902 were hospitalized and 468 had a diagnosis of asthma (4.4%). When adjusted for COVID-19 disease severity, comorbidities, and concurrent therapies, patients with asthma had a lower mortality (adjusted odds ratio [OR], 0.64 (0.53-0.77); P < .001) and a lower rate of hospitalization and intensive care unit admission (OR, 0.43 (0.28-0.64); P < .001 and OR, 0.51 (0.41-0.64); P < .001, respectively). Those with blood eosinophils greater than or equal to 200 cells/μL, both with and without asthma, had lower mortality. ConclusionPatients with asthma may be at a reduced risk of poor outcomes from COVID-19 infection. Eosinophilia, both in those with and without asthma, may be associated with reduced mortality risk.

Characteristics and Outcomes of Endoscopies before and during the COVID-19 Pandemic in New York

Introduction: The COVID-19 pandemic drastically changed hospital workflows. This study aimed to characterize differences in gastrointestinal endoscopies in the New York metropolitan region before, during, and after the first wave of the pandemic. Methods: Across 3 hospitals, we compared demographics, indications, and yield of endoscopies before and after March 16, 2020, the date on which elective procedures were canceled, as well as a recovery period for 5 months after they were resumed. Results: A total of 9,401 procedures before and 332 procedures during the first wave were performed. Females comprised 57 and 44% of patients (p < 0.01), respectively. There was a decline in the proportion of Black (15 vs. 7%, p < 0.02) and Hispanic patients (29 vs. 16%, p < 0.02) undergoing outpatient procedures. There was a significant rise in urgent indications such as bleeding and jaundice. There was an increase in the diagnostic yield of all esophagogastroduodenoscopies for bleeding (p < 0.01) and of outpatient endoscopic ultrasounds for malignancy (p = 0.01), but no increase in yield of inpatient colonoscopy for bleeding. A review of 7,475 procedures during the recovery period showed a return to many nonurgent indications, but still showed decreased proportions of Hispanic and male patients compared to the prepandemic period. Discussion/Conclusion: Lower proportions of Black and Hispanic patients underwent outpatient endoscopies during and after the first wave. The proportion of procedures done for emergent indications and their diagnostic yield increased during the pandemic, suggesting a higher threshold to perform endoscopy. In resource-sparing conditions, clinicians should pay attention to thresholds to perform colonoscopy for bleeding and to racial disparities in outpatient healthcare access.

A Spatial Analysis on Charter School Access in the New York Metropolitan Area

Background Extant literature has consistently indicated that access to charter school markets is shaped by social geography. Given interest in location shown by charter schools and parents, estimating potential spatial access to charter schools has become instrumental in understanding equal opportunities for charter school enrollment in metropolitan areas with preexisting residential segregation. Purpose By considering the increasing significance of sociogeography, this article asks whether students have equal opportunities for potential spatial access to charter schools across communities and how disparities in charter school access are related to housing patterns. Setting This study focuses on 122 charter schools in the New York metropolitan region, a highly segregated metropolitan area in the United States where charter schools are a primary component of education reform. Research Design The first part of this study illustrates patterns of spatial accessibility of the area's charter schools, within a 20-minute commuting time, to students aged 5–13 years by employing the enhanced two-step floating catchment area method using a Gaussian function. The next part of the study tests the hypothesis that students are able to access charter schools equitably and irrespective of their place of residence. The spatial lag regression model is used to compare distributions of potential spatial accessibility with 15 demographic and socioeconomic variables. Findings Even after controlling for disproportionate population sizes by census tract, the potential need for charter schools is matched inequitably with the supply of educational service providers. The spatial lag regression results indicate that children in areas less accessible to charter schools within a convenient travel period tend to be exposed to communities with more populations of color, higher unemployed groups, and less expensive housing. Conclusions The findings offer empirical evidence that access to charter school differs depending on demographic and socioeconomic attributes, in significant combination with geography, illuminating charter school location strategies in real-world contexts. Though charter schools have been promoted as a vehicle to offer significant equity advantages across politically designed and strictly operated school attendance boundaries, charter schools in metropolitan New York exercise a distinct and profound form of pseudo-zoning by use of location strategies to exclude certain children who may be considered less desirable.

Efficacy of corticosteroids in non-intensive care unit patients with COVID-19 pneumonia from the New York Metropolitan region.

IntroductionThe role of systemic corticosteroid as a therapeutic agent for patients with COVID-19 pneumonia is controversial.ObjectiveThe purpose of this study was to evaluate the effect of corticosteroids in non-intensive care unit (ICU) patients with COVID-19 pneumonia complicated by acute hypoxemic respiratory failure (AHRF).MethodsThis was a single-center retrospective cohort study, from 16th March, 2020 to 30th April, 2020; final follow-up on 10th May, 2020. 265 patients consecutively admitted to the non-ICU wards with laboratory-confirmed COVID-19 pneumonia were screened for inclusion. 205 patients who developed AHRF (SpO2/FiO2 ≤ 440 or PaO2/FiO2 ≤ 300) were only included in the final study. Direct admission to the Intensive care unit (ICU), patients developing composite primary outcome within 24 hours of admission, and patients who never became hypoxic during their stay in the hospital were excluded. Patients were divided into two cohorts based on corticosteroid. The primary outcome was a composite of ICU transfer, intubation, or in-hospital mortality. Secondary outcomes were ICU transfer, intubation, in-hospital mortality, discharge, length of stay, and daily trend of SpO2/FiO2 (SF) ratio from the index date. Cox-proportional hazard regression was implemented to analyze the time to event outcomes.ResultAmong 205 patients, 60 (29.27%) were treated with corticosteroid. The mean age was ~57 years, and ~75% were men. Thirteen patients (22.41%) developed a primary composite outcome in the corticosteroid cohort vs. 54 (37.5%) patients in the non-corticosteroid cohort (P = 0.039). The adjusted hazard ratio (HR) for the development of the composite primary outcome was 0.15 (95% CI, 0.07–0.33; P <0.001). The adjusted hazard ratio for ICU transfer was 0.16 (95% CI, 0.07 to 0.34; P < 0.001), intubation was 0.31 (95% CI, 0.14 to 0.70; P– 0.005), death was 0.53 (95% CI, 0.22 to 1.31; P– 0.172), composite of death or intubation was 0.31 (95% CI, 0.15 to 0.66; P– 0.002) and discharge was 3.65 (95% CI, 2.20 to 6.06; P<0.001). The corticosteroid cohort had increasing SpO2/FiO2 over time compared to the non-corticosteroid cohort who experience decreasing SpO2/FiO2 over time.ConclusionAmong non-ICU patients hospitalized with COVID-19 pneumonia complicated by AHRF, treatment with corticosteroid was associated with a significantly lower risk of the primary composite outcome of ICU transfer, intubation, or in-hospital death, composite of intubation or death and individual components of the primary outcome.

Disability, wages, and commuting in New York

In the U.S., substantial employment and wage gaps persist between workers with and without disabilities. A lack of accessible transportation is often cited as a barrier to employment in higher wage jobs for people with disabilities, but little is known about the intraurban commuting patterns of employed people with disabilities in relation to their wage earnings. Our study compares wages and commute times between workers with and without disabilities in the New York metropolitan region and identifies the intraurban zones where residents experience higher inequities in wage earnings and commute times. We obtained our data from the Public Use Microdata Sample (PUMS) of the American Community Survey (ACS) for the 2008–2012 time period. We used linear mixed-effects models and generated separate models with log hourly wage or one-way commute time as the dependent variable. We find significant differences in wages and commute times between workers with and without disabilities at the scale of the metropolitan region as well as by intraurban zone. At the metropolitan scale, disabled workers earn 16.6% less and commute one minute longer on average than non-disabled workers. High commute and wage inequalities converge in the center, where workers with disabilities are more likely to use public transit, earn 17.1% less, and travel nearly four minutes longer on average than workers without disabilities. These results suggest that transport options are less accessible and slower for disabled workers than they are for non-disabled workers. Our findings indicate a need for more accessible and quicker forms of transportation in the center along with an increased availability of centrally located and affordable housing to reduce the disability gap in wages and commute times. We also find that workers with disabilities generally seek higher wages in exchange for longer commute times, but the results differ by race/ethnicity and gender. Compared to white men, minority workers earn much less, and white and Hispanic women have significantly shorter commute times. Our findings offer new geographic insights on how having a disability can influence wage earnings and commute times for workers in different intraurban zones in the New York metropolitan region.

Creation of a dedicated line service in the New Jersey epicenter of COVID-19

As part of the New York Metropolitan region, New Jersey follows New York, becoming the second largest epicenter of SARS-coronavirus 2 (COVID-19) infection in the United States during this pandemic. Hackensack Meridian Health, the largest health care system in New Jersey, continues to seek innovative and practical ways to battle this pandemic. On March 15, we issued a policy to temporarily postpone nonurgent and nonemergency hospital and campus-based operations and procedures for 2 weeks in anticipation of an expected surge of patients.

Cancellation of Elective Surgery and Intensive Care Unit Capacity in New York State: A Retrospective Cohort Analysis.

BACKGROUND:In response to the coronavirus disease 2019 (COVID-19) pandemic, New York State ordered the suspension of all elective surgeries to increase intensive care unit (ICU) bed capacity. Yet the potential impact of suspending elective surgery on ICU bed capacity is unclear.METHODS:We retrospectively reviewed 5 years of New York State data on ICU usage. Descriptions of ICU utilization and mechanical ventilation were stratified by admission type (elective surgery, emergent/urgent/trauma surgery, and medical admissions) and by geographic location (New York metropolitan region versus the rest of New York State). Data are presented as absolute numbers and percentages and all adult and pediatric ICU patients were included.RESULTS:Overall, ICU admissions in New York State were seen in 10.1% of all hospitalizations (n = 1,232,986/n = 12,251,617) and remained stable over a 5-year period from 2011 to 2015. Among n = 1,232,986 ICU stays, sources of ICU admission included elective surgery (13.4%, n = 165,365), emergent/urgent admissions/trauma surgery (28.0%, n = 345,094), and medical admissions (58.6%, n = 722,527). Ventilator utilization was seen in 26.3% (n = 323,789/n = 1232,986) of all ICU patients of which 6.4% (n = 20,652), 32.8% (n = 106,186), and 60.8% (n = 196,951) was for patients from elective, emergent, and medical admissions, respectively. New York City holds the majority of ICU bed capacity (70.0%; n = 2496/n = 3566) in New York State.CONCLUSIONS:Patients undergoing elective surgery comprised a small fraction of ICU bed and mechanical ventilation use in New York State. Suspension of elective surgeries in response to the COVID-19 pandemic may thus have a minor impact on ICU capacity when compared to other sources of ICU admission such as emergent/urgent admissions/trauma surgery and medical admissions. More study is needed to better understand how best to maximize ICU capacity for pandemics requiring heavy use of critical care resources.

Disaster Response to the COVID-19 Pandemic for Patients with Kidney Disease in New York City.

The novel coronavirus disease 2019 (COVID-19) was first identified in Wuhan, China in December 2019.[1][1] Since then, the New York metropolitan region has quickly become the epicenter of the COVID-19 pandemic in the United States, with >175,000 cases and >20,000 deaths to date.[2][2] The Columbia

From prophecy to projection: the New York Metropolitan Region Study and the rescaling of the urban future, 1956–1968

ABSTRACT Between 1956 and 1959, amid far-flung residential and industrial suburbanization and with the joint backing of the Rockefeller Foundation, the Ford Foundation, and the Twentieth Century Fund, an interdisciplinary coterie of scholars from Harvard partnered with New York’s Regional Plan Association to produce a widely read ten-volume ‘projection’ of what the physical plant, political economy, and everyday lives of that metropolis would look like in 1985. This paper considers the New York Metropolitan Region Study as a peculiar, consequential exercise in how postwar urbanists recast urban temporality. Rejecting both the certainties of prophecy and the hazards of mere prediction, the Study sought to establish a new tense for urbanism and a newly disciplined set of methods for making inferences about the urban future on the basis of the past and present. The constituent volumes of the NYMRS garnered various degrees of influence in isolation. The sum total both furthered acceptance of a regional scale of operations for planning and decisively chastened hopes for political intervention on urban and regional futures.

The care of pregnant women during the COVID-19 pandemic - response of a large health system in metropolitan New York.

The rapid progression of the coronavirus disease 2019 (COVID-19) outbreak presented extraordinary challenges to the US health care system, particularly straining resources in hard hit areas such as the New York metropolitan region. As a result, major changes in the delivery of obstetrical care were urgently needed, while maintaining patient safety on our maternity units. As the largest health system in the region, with 10 hospitals providing obstetrical services, and delivering over 30,000 babies annually, we needed to respond to this crisis in an organized, deliberate fashion. Our hospital footprint for Obstetrics was dramatically reduced to make room for the rapidly increasing numbers of COVID-19 patients, and established guidelines were quickly modified to reduce potential staff and patient exposures. New communication strategies were developed to facilitate maternity care across our hospitals, with significantly limited resources in personnel, equipment, and space. The lessons learned from these unexpected challenges offered an opportunity to reassess the delivery of obstetrical care without compromising quality and safety. These lessons may well prove valuable after the peak of the crisis has passed.

Association of Treatment With Hydroxychloroquine or Azithromycin With In-Hospital Mortality in Patients With COVID-19 in New York State

Hydroxychloroquine, with or without azithromycin, has been considered as a possible therapeutic agent for patients with coronavirus disease 2019 (COVID-19). However, there are limited data on efficacy and associated adverse events. To describe the association between use of hydroxychloroquine, with or without azithromycin, and clinical outcomes among hospital inpatients diagnosed with COVID-19. Retrospective multicenter cohort study of patients from a random sample of all admitted patients with laboratory-confirmed COVID-19 in 25 hospitals, representing 88.2% of patients with COVID-19 in the New York metropolitan region. Eligible patients were admitted for at least 24 hours between March 15 and 28, 2020. Medications, preexisting conditions, clinical measures on admission, outcomes, and adverse events were abstracted from medical records. The date of final follow-up was April 24, 2020. Receipt of both hydroxychloroquine and azithromycin, hydroxychloroquine alone, azithromycin alone, or neither. Primary outcome was in-hospital mortality. Secondary outcomes were cardiac arrest and abnormal electrocardiogram findings (arrhythmia or QT prolongation). Among 1438 hospitalized patients with a diagnosis of COVID-19 (858 [59.7%] male, median age, 63 years), those receiving hydroxychloroquine, azithromycin, or both were more likely than those not receiving either drug to have diabetes, respiratory rate >22/min, abnormal chest imaging findings, O2 saturation lower than 90%, and aspartate aminotransferase greater than 40 U/L. Overall in-hospital mortality was 20.3% (95% CI, 18.2%-22.4%). The probability of death for patients receiving hydroxychloroquine + azithromycin was 189/735 (25.7% [95% CI, 22.3%-28.9%]), hydroxychloroquine alone, 54/271 (19.9% [95% CI, 15.2%-24.7%]), azithromycin alone, 21/211 (10.0% [95% CI, 5.9%-14.0%]), and neither drug, 28/221 (12.7% [95% CI, 8.3%-17.1%]). In adjusted Cox proportional hazards models, compared with patients receiving neither drug, there were no significant differences in mortality for patients receiving hydroxychloroquine + azithromycin (HR, 1.35 [95% CI, 0.76-2.40]), hydroxychloroquine alone (HR, 1.08 [95% CI, 0.63-1.85]), or azithromycin alone (HR, 0.56 [95% CI, 0.26-1.21]). In logistic models, compared with patients receiving neither drug cardiac arrest was significantly more likely in patients receiving hydroxychloroquine + azithromycin (adjusted OR, 2.13 [95% CI, 1.12-4.05]), but not hydroxychloroquine alone (adjusted OR, 1.91 [95% CI, 0.96-3.81]) or azithromycin alone (adjusted OR, 0.64 [95% CI, 0.27-1.56]), . In adjusted logistic regression models, there were no significant differences in the relative likelihood of abnormal electrocardiogram findings. Among patients hospitalized in metropolitan New York with COVID-19, treatment with hydroxychloroquine, azithromycin, or both, compared with neither treatment, was not significantly associated with differences in in-hospital mortality. However, the interpretation of these findings may be limited by the observational design.