Faculty Bibliography

Background : The 2019 novel coronavirus disease (COVID-19) is associated with significant thrombotic complications, contributing to the excess mortality observed with severe disease. Currently, there is insufficient evidence to support therapeutic dose anticoagulation in hospitalized COVID-19 patients outside of clinical trials. There is a greater need to understand the epidemiological and clinical factors associated with thrombotic complications. Aims : To investigate the clinical characteristics in self-reported Asian race, who were hospitalized with COVID-19 early in the pandemic and the incidence of thrombosis. Methods : We conducted a retrospective observational study of index hospitalizations for all patients, age >= 18, with confirmed SARS-CoV-2 infection between March 13 and April 4, 2020 across two hospitals in New York City. Clinical demographics including selfreported race and admission labs were collected. Confirmed arterial and/or venous thrombosis were confirmed with imaging during the encounter with chart review. Results : There were 118 patients, who self-identified as Asian, hospitalized with COVID-19 during the study period. During their hospitalization, there were 24 patients (20.3%) who experienced thrombotic event during their encounter. There were 14 events described as venous thrombosis (7 deep venous thrombosis, 6 pulmonary embolisms, 1 superficial vein thrombosis) and 10 who experienced an arterial thrombosis (5 cerebrovascular accidents, 4 myocardial infarctions and 1 with splenic infarction). Body mass index ( P = 0.027) and a history of cancer ( P = 0.026) were significant demographic factors associated with thrombosis. D-dimer ( P = 0.045), C-reactive protein ( P < 0.001), ferritin ( P = 0.024) and troponin I ( P = 0.036) were significantly elevated on admission. Conclusions : There are differences in clinical characteristics on admission in self-identified Asians, associated with thrombosis in COVID-19. Understanding these associated factors is helpful to delineate both the spectrum and pathophysiology of COVID-19

BACKGROUND:The authors sought to study the risk factors associated with severe outcomes in hospitalized coronavirus disease 2019 (COVID-19) patients with cancer. METHODS:The authors queried the New York University Langone Medical Center's records for hospitalized patients who were polymerase chain reaction-positive for severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) and performed chart reviews on patients with cancer diagnoses to identify patients with active cancer and patients with a history of cancer. Descriptive statistics were calculated and multivariable logistic regression was used to determine associations between clinical, demographic, and laboratory characteristics with outcomes, including death and admission to the intensive care unit. RESULTS:A total of 4184 hospitalized SARS CoV-2+ patients, including 233 with active cancer, were identified. Patients with active cancer were more likely to die than those with a history of cancer and those without any cancer history (34.3% vs 27.6% vs 20%, respectively; P < .01). In multivariable regression among all patients, active cancer (odds ratio [OR], 1.89; CI, 1.34-2.67; P < .01), older age (OR, 1.06; CI, 1.05-1.06; P < .01), male sex (OR for female vs male, 0.70; CI, 0.58-0.84; P < .01), diabetes (OR, 1.26; CI, 1.04-1.53; P = .02), morbidly obese body mass index (OR, 1.87; CI, 1.24-2.81; P < .01), and elevated D-dimer (OR, 6.41 for value >2300; CI, 4.75-8.66; P < .01) were associated with increased mortality. Recent cancer-directed medical therapy was not associated with death in multivariable analysis. Among patients with active cancer, those with a hematologic malignancy had the highest mortality rate in comparison with other cancer types (47.83% vs 28.66%; P < .01). CONCLUSIONS:The authors found that patients with an active cancer diagnosis were more likely to die from COVID-19. Those with hematologic malignancies were at the highest risk of death. Patients receiving cancer-directed therapy within 3 months before hospitalization had no overall increased risk of death. LAY SUMMARY/UNASSIGNED:Our investigators found that hospitalized patients with active cancer were more likely to die from coronavirus disease 2019 (COVID-19) than those with a history of cancer and those without any cancer history. Patients with hematologic cancers were the most likely among patients with cancer to die from COVID-19. Patients who received cancer therapy within 3 months before hospitalization did not have an increased risk of death.

Objective New York City (NYC) became the first epicenter of the 2019 novel coronavirus disease (COVID-19) in the United States. Factors upon admission associated with the development of thrombosis in hospitalized COVID-19 patients are less well defined. Our aim is to characterize the incidence of thrombosis and the associated clinical and demographic risk factors of patients hospitalized across a NYC hospital system. Material and Methods We conducted a retrospective observational study of all patients, age >= 18, hospitalized with a reverse transcriptase-polymerase chain reaction confirming severe acute respiratory syndrome coronavirus 2 infection between March 13 and April 4, 2020 in two hospitals in NYC. Clinical demographics, admission labs and medications prior to admission were collected. Thrombotic events were identified manually by chart review and were defined as experiencing arterial and/or venous thrombotic events. Results 1,352 patients were hospitalized during the study period. Overall median age was 62 years (IQR:49-72), with 455 females (33.7%). There were 160 (11.8%) thrombotic events, including 102 with venous thromboembolism, 45 with pulmonary embolism, 69 with deep vein thrombosis, 32 with cerebrovascular accident and 55 with other thrombotic events (e.g. myocardial infarction, acute limb ischemia, splenic infarct). Females were 46% less likely than males to experience a thrombotic event (OR:0.54[CI:0.36-0.79]). Patients who racially self-identify as Asian or Pacific Islander were observed to have a 2.06 odds compared to other races of having a thrombotic event with COVID-19 (95%[CI:1.27-3.34]). Traditional risk factors including age, admission BMI, ethnicity, smoking status, and comorbidities were not associated with the incidence of thrombosis during hospitalization. Thrombotic events were associated with higher mortality in hospitalized COVID-19 patients (35% vs 25.3%, p=0.009). Conclusion Traditional risk factors were not associated with an increased risk for thrombotic events in COVID-19 patients, while inflammatory marker values on admission were significantly different, highlighting the impact of the cytokine storm in mediating thrombotic events. Since the incidence of COVID-19-associated thrombosis may vary according to clinical demographics, further investigation to identify high risk patients may enable us to consider the role of adjunctive treatment, such as therapeutic coagulation. (Table Presented)

LEARNING OBJECTIVE #1: Recognize a broad differential diagnosis of encephalopathy LEARNING OBJECTIVE #2: Recognize presentation and management of chemotherapy-induced encephalopathy CASE: A 70-year-old woman with a history of relapsed marginal zone B cell lymphoma (MZL) presented with 1-week of progressive cognitive decline, confusion, and generalized weakness. Upon admission, she had Citrobacter and Proteus urinary tract infection and was treated with ceftriaxone. Despite antibiotic treatment, patient continued to have fluctuating encephalopathy and episodes of neurological focality prompting multiple stroke codes with unremarkable brain imaging findings. Electroencephalogram showed diffuse slowing but no definite epileptiform activity. Patient was started on levetiracetam empirically with no improvement. Other workup was notable for cerebrospinal fluid (CSF) studies with lymphocytic pleocytosis, moderate protein elevation and normal glucose levels. Cytology and flow cytometry repeatedly revealed presence of increased number of atypical lymphocytes with abscence of an immunophenotypic evidence of a lymphoproliferative disorder. CSF meningitis/encephalitis panel, paraneoplastic panel, JC virus PCR, cryptococcal antigen, CSF cultures, blood cultures, and repeat urine culture were negative. MRI spine showed nonspecific diffuse mild enhancement of the cauda equina nerve roots. Patient's past medical history was notable for MZL diagnosed in 2012. She was treated with intravenous (IV) high dose methotrexate (HDMTX) and rituximab, followed by maintenance rituximab. One month prior to hospitalization, patient had recurrent disease with CNS involvement and received IV HDMTX and intrathecal (IT) cytarabine. Given unrevealing workup, it was speculated that patient's presentation may have been caused by a chemical meningitis/CNS toxicity from concurrent IV HDMTX and IT cytarabine. Patient was treated with dexamethasone which resulted in marked improvement in her mental status. IMPACT/DISCUSSION: The differential of encephalopathy is broad. The possibility of CNS involvement from MZL was low given negative CSF studies. An infectious etiology was also unlikely given many negative cultures and viral studies. No metabolic derangements were noted. EEG and brain MRI were not suggestive of seizure or other neurologic etiology. Given concern for neurotoxicity from systemic chemotherapy, patient was treated with steroids to reduce the inflammation and speed up neurological recovery.
CONCLUSION(S): We report an interesting case of an elderly woman with relapsed MZL with CNS involvement who presented with fluctuating encephalopathy and underwent a negative hematologic, neurologic, infectious, and metabolic workup except CSF studies with lymphocytic pleocytosis, moderate protein elevation and normal glucose levels and MRI spine with mild enhancement of the cauda equina nerve roots. This case emphasizes the importance of maintaining a high clinical suspicion for chemotherapy-induced encephalopathy in patients who recently received systemic chemotherapy

BACKGROUND: New York City became the epicenter of the COVID-19 pandemic in the US, reporting its first case of SARS-CoV-2 on March 1, 2020. Patients with co-morbid conditions such as hypertension and diabetes are disproportionately impacted by COVID-19. Hospital systems have been burdened nationwide, including community and safety-net hospitals who serve medically underserved populations, placing them at risk from a resource-needs standpoint. Our study aim is to describe the clinical presentation and outcomes of hospitalized patients with COVID-19, and to highlight the burden on community hospitals, in order to guide health policy and resource allocation in future crises.
METHOD(S): We conducted a retrospective case series of patients admitted to NYU Langone Hospital - Brooklyn between March 13th and April 4th, 2020. Reverse-transcriptase polymerase chain reaction nasopharyngeal swab confirmed infection with the SARS-CoV-2 virus. Clinical demographics were obtained from the electronic health record (Epic Hyperspace, Madison, WI). The primary outcome was time-to-event, defined as transfer to an intensive care unit, mechanical ventilation or death from time of admission. Statistical analysis was performed using Stata SE 16 (StataCorp, College Station, TX).
RESULT(S): There were 561 patients admitted with a median age of 61 years(IQR 48-74). See Table 1. The median time to composite event was 4.13 days(IQR: 2.23-7.97).
CONCLUSION(S): Our results show that the impact of COVID-19 on a community hospital is similar to what has been reported in the literature for tertiary centers, implying that safety-net hospitals can play an integral role in future impact mitigation. These implications hold true as the pandemic continues to disproportionately affect those with chronic diseases. As cases of COVID-19 near 20 million, our experience positions us as harbingers who can provide insight for resource allocation across the US. LEARNING OBJECTIVE #1: Patient Care: Identify the characteristics in patients with COVID-19 associated with increased risk for hospitalization LEARNING OBJECTIVE #2: Medical Knowledge: Understand the outcomes related to COVID-19 in a diverse population