Faculty Bibliography

BACKGROUND:Despite evidence of socio-demographic disparities in outcomes of COVID-19, little is known about characteristics and clinical outcomes of patients admitted to public hospitals during the COVID-19 outbreak. OBJECTIVE:To assess demographics, comorbid conditions, and clinical factors associated with critical illness and mortality among patients diagnosed with COVID-19 at a public hospital in New York City (NYC) during the first month of the COVID-19 outbreak. DESIGN/METHODS:Retrospective chart review of patients diagnosed with COVID-19 admitted to NYC Health + Hospitals / Bellevue Hospital from March 9th to April 8th, 2020. RESULTS:A total of 337 patients were diagnosed with COVID-19 during the study period. Primary analyses were conducted among those requiring supplemental oxygen (n = 270); half of these patients (135) were admitted to the intensive care unit (ICU). A majority were male (67.4%) and the median age was 58 years. Approximately one-third (32.6%) of hypoxic patients managed outside the ICU required non-rebreather or non-invasive ventilation. Requirement of renal replacement therapy occurred in 42.3% of ICU patients without baseline end-stage renal disease. Overall, 30-day mortality among hypoxic patients was 28.9% (53.3% in the ICU, 4.4% outside the ICU). In adjusted analyses, risk factors associated with mortality included dementia (adjusted risk ratio (aRR) 2.11 95%CI 1.50-2.96), age 65 or older (aRR 1.97, 95%CI 1.31-2.95), obesity (aRR 1.37, 95%CI 1.07-1.74), and male sex (aRR 1.32, 95%CI 1.04-1.70). CONCLUSION/CONCLUSIONS:COVID-19 demonstrated severe morbidity and mortality in critically ill patients. Modifications in care delivery outside the ICU allowed the hospital to effectively care for a surge of critically ill and severely hypoxic patients.

Contact tracing has been a key element of the public health response to infectious diseases for decades. These practices have been powerful in slowing the spread of tuberculosis, HIV, and other sexually transmitted infections. Despite success in other contexts, contact tracing for hepatitis C virus (HCV) has historically been considered infeasible because of a long asymptomatic period, which often makes it difficult to pinpoint the time of acquisition. Additionally, individuals may be reluctant to identify injecting partners because of stigma or fear of criminal repercussions. However, multiple factors - including the improved curability of HCV with advances in direct acting antiviral agents (DAAs), the implementation of age-based screening, and the current opioid epidemic -- have led to rapid changes in the landscape of HCV. HCV is increasingly concentrated among young people who inject drugs (PWID), many of whom are inadequately being reached by current screening practices. With the shift in the population most at risk for HCV and the fundamental changes in how we manage this disease, it's time to also rethink the public health response in identifying and informing those who may have been exposed. Contact tracing programs for HCV can augment existing screening strategies to provide curative treatment for patients and their partners, prevent reciprocal transmission of HCV between risk partners and within networks, and ultimately reach individuals who aren't yet engaged in healthcare and harm reduction. While there remain limitations to contact tracing for HCV, it has the potential to be a powerful tool in slowing the spread of the virus as we attempt to achieve viral elimination.

Background. To achieve hepatitis C elimination, treatment programs need to be developed to engage, treat, and cure people who are actively injecting drugs. Methods. We present preliminary data from the first 65 participants in the Accessible Care intervention for engaging people who inject illicit drugs (PWID) in hepatitis C (HCV) care. The randomized clinical trial compares the effectiveness of Accessible Care (low-threshold care in a syringe service program located in New York City) with Usual Care (referral to existing services) in facilitating linkage, engagement, and retention in HCV care. Eligible participants were HCV RNA positive and had injected drugs in the past 90 days. We compared the percentage of participants in each arm linked to HCV care (defined as one visit with HCV treatment provider), and initiated direct-acting antiviral (DAA) treatment within 6 months of enrollment. Results. Among the 65 participants, the mean age is 41.2 years; 28% are females; 73% homeless; 6% black, 51% Latina/o and 39% white. 82% of participants had injected drugs in the last 30 days, with an average of 13.2 injections/month (median 10). Nearly all participants had health insurance, 88% public insurance, 6% uninsured. Thirty-two participants were randomized to the Accessible Care arm. Within 6 months of enrollment 79% of the Accessible Care arm and 25% of the Usual Care arm had linked to HCV care, and 69% and 13% had been started on DAA therapy, respectively. Of the 26 participants in the Accessible Care arm started on DAA therapy, the median time from enrollment to treatment initiation was 87.5 days [range 22-180]. Conclusion. Among HCV-infected PWID enrolled at a syringe service program, higher rates of linkage to care and treatment initiation were seen in the Accessible Care arm where stigma- and shame-free treatment was located within a community-based location

Background. ID physicians often treat the infectious sequelae of opioid use dis-order (OUD) and are uniquely poised to link hospitalized patients to substance use resources. In a large safety net hospital, we launched a multi-disciplinary initiative to -cation-assisted treatment (MAT). We used infections as "sentinel" events to identify patients with OUD and described the clinical characteristics of the high-risk patient population jointly consulted by ID and Psychiatry teams. This healthcare workforce initiative aimed to expand the role of ID providers in the opioid epidemic and decrease barriers to buprenorphine prescribing. Every 2 weeks, ID fellows identified patients on their consult lists with infectious complications of OUD. Focused discussions were then held with the Psychiatry service and discussion of each patient continued at subsequent case confer-ences with attention paid to re-engaging those lost to follow-up. We performed chart abstraction of demographic and clinical characteristics as part of a quality improve-Results. From October 2018 to March 2019, 23 patients were discussed at 10 case conferences with input from attendings, fellows, housestaff, social workers, and repre-sentatives from a novel Primary Care Safety Net program. The average patient age was 43 (range 24-50). Patients were predominantly male (65%), heroin users (90%) with high rates of HIV (22%) and untreated HCV (40%). ID-related infections included endocarditis (39%), osteomyelitis (31%), skin and soft-tissue infections (17%) and spinal abscesses (17%). The median time for a patient to be presented at an ID-Psych Addiction Rounds was 7 days (IQR 4.5-11.5). The mean length of hospitalization was 30 days (range 2-112). MAT was initiated in 75% of patients (41% buprenorphine; 59% methadone). The 30-day lost to follow-up rate was exceedingly high, with 80% of post-hospital appointments being missed. Conclusion. ID physicians can effectively link hospitalized patients with OUD to substance use resources. A multi-disciplinary approach is key to addressing the opioid epidemic. Future work should explore how to create effective post-hospital transitions to decrease those lost to follow-up

BACKGROUND:Hepatitis C virus (HCV) is a major public health problem in correctional settings. HCV treatment is often not possible in U.S. jails due to short lengths of stay. Linkage to care is crucial in these settings, but competing priorities complicate community healthcare engagement and retention after incarceration. METHODS:We conducted a single arm clinical trial of a combined transitional care coordination (TCC) and patient navigation intervention and assessed the linkage rate and factors associated with linkage to HCV care after incarceration. RESULTS:During the intervention, 84 participants returned to the community after their index incarceration. Most participants were male and Hispanic, with a history of mental illness and a mean age of 45 years. Of those who returned to the community, 26 (31%) linked to HCV care within a median of 20.5 days; 17 (20%) initiated HCV treatment, 15 (18%) completed treatment, 9 (11%) had a follow-up lab drawn to confirm sustained virologic response (SVR), and 7 (8%) had a documented SVR. Among those with follow-up labs the known SVR rate was (7/9) 78%. Expressing a preference to be linked to the participant's existing health system, being on methadone prior to incarceration, and feeling that family or a loved one were concerned about the participant's wellbeing were associated with linkage to HCV care. Reporting drinking alcohol to intoxication prior to incarceration was negatively associated with linkage to HCV care. CONCLUSION/CONCLUSIONS:We demonstrate that an integrated strategy with combined TCC and patient navigation may be effective in achieving timely linkage to HCV care. Additional multicomponent interventions aimed at treatment of substance use disorders and increasing social support could lead to further improvement. TRIAL REGISTRATION/BACKGROUND:Clinicaltrials.gov NCT04036760 July 30th, 2019 (retrospectively registered).

Hepatitis C virus (HCV) is a significant public health problem that disproportionately afflicts people who inject drugs. We describe outcomes of HCV treatment co-located within a syringe services program (SSP). Fifty-three participants started therapy, and 91% achieved sustained virologic response. SSPs provide an effective venue for HCV treatment.

We report the case of a 46-year-old man abattoir worker who developed myalgias, shortness of breath, and irritability 2 weeks after sustaining a laceration to the hand with a knife at work. During his hospital evaluation for septic shock he was noted to be febrile, hypotensive, profoundly jaundiced with aseptic meningitis, and renal failure, and was diagnosed with Leptospirosis interrogans infection confirmed by serum and urine polymerase chain reaction. After standard antibiotic therapy and recovery from severe clinical illness, he developed unilateral orchitis with pyuria secondary to leptospirosis, a well-established complication in the veterinary literature, but of which we offer the first report in humans in the English literature. The case presented was also the index case that uncovered a cluster outbreak of leptospirosis in New York City during the winter of 2016-2017, involving a total of three patients who lived or worked within a block of the abattoir. Two patients survived whereas the third died of pulmonary hemorrhage shortly after seeking medical care.

BACKGROUND: Hepatitis C virus (HCV) infection remains a significant problem in the United States, with people who inject drugs (PWID) disproportionately afflicted. Over the last decade rates of heroin use have more than doubled, with young persons (18-25 years) demonstrating the largest increase. METHODS: We conducted a cross-sectional study in New York City from 2005 to 2012 among young people who injected illicit drugs, and were age 18 to 35 or had injected drugs for