Faculty Bibliography

We investigated the proportion of mpox hospitalizations for medical indications versus infection control isolation at New York University Langone Health and NYC Health + Hospitals from May 1, 2022, through April 28, 2023. We reviewed the electronic medical records of people with a positive mpox nucleic acid amplification test independently. We collected demographic and clinical data on those who met our inclusion criteria, and we stratified patients by medical indication or infection control isolation based on their reason for hospitalization. This observational cohort study included 66 patients admitted for mpox, of whom 8 (12.1%) were admitted primarily for infection control isolation and 58 (87.9%) were admitted primarily for medical indications. Those hospitalized primarily for isolation (vs medical indications) were significantly less likely to have a private residence (25.0% vs 79.3%; P < .001). Those hospitalized for medical indications (vs isolation) were significantly more likely to be HIV positive (63.8% vs 12.5%; P = .006), to have secondary bacterial infections (65.5% vs 25.0%; P = .03), and to receive antibiotics (81.0% vs 25.0%; P < .001). We found no significant differences in the median cumulative length of stay per patient or the proportion of tecovirimat receipt between the 2 groups. While the small size of the isolation cohort was a limitation of this analysis, our findings argue for increased capacity for community-based isolation, which may reduce the use of hospital admissions primarily for infection control isolation in future outbreaks.

BACKGROUND:The 2022-2023 global mpox outbreak predominantly affected sexual minority men, with notable racial/ethnic disparities in the USA. While the current literature has established the clinical predictors of severe mpox disease, little is known about the role of insurance status on clinical outcomes. We sought to characterize patients diagnosed with mpox in New York City (NYC) and examine associations between insurance status and mpox severity score (mpox-SS). METHODS:), prior vaccination with JYNNEOS or a smallpox vaccine, presence of a sexually transmitted infection (STI), and CDC Social Vulnerability Index. RESULTS:The mean age (SD) was 38.3 (10.2) years with 53 (37.1%) identifying as non-Hispanic White, 44 (30.8%) as Hispanic/Latino, and 30 (20.9%) as non-Hispanic Black. Over 90% were male sex at birth or identified as cisgender men and approximately 80% were sexual minority men. Ninety-six (67.1%) had private insurance, 6 (4.2%) Medicare, 35 (24.5%) Medicaid, and 4 were (2.8%) uninsured. Sixty-three (44.1%) had a confirmed HIV diagnosis, 25 (17.4%) patients had prior JYNNEOS vaccination, and 31 (21.7%) had a high-risk condition. Thirty-eight (26.6%) patients received tecovirimat; 21 (14.7%) patients were hospitalized, with 4 (2.8%) of those admitted to the ICU. The mean (SD) mpox-SS was 6.85 (3.36). In univariate analysis, lack of insurance or Medicaid status was associated significantly with more severe mpox-SS. Insurance status remained significant (p = 0.03) in multivariable models. CONCLUSIONS:Being uninsured or on Medicaid was significantly associated with a higher mpox-SS in this diverse cohort of predominantly cisgender sexual minority men in NYC. High-risk status and lack of prior vaccination were associated with higher mpox-SS. Further studies are needed to assess the relationship between insurance, delays in access to care, or other socioeconomic inequities with severe mpox to understand the inequities beyond insurance access to prevent disparities in future outbreaks.

OBJECTIVE/UNASSIGNED:A follow-up survey of Special Pathogen Treatment Centers (SPTCs) was conducted to assess their readiness to provide critical care interventions to confirmed and suspected viral hemorrhagic fever (VHF) patients after the COVID-19 pandemic. METHODS/UNASSIGNED:An electronic survey with 54 multiple-choice and free-response questions assessing VHF critical care capabilities was sent to 74 US SPTCs in April 2023. RESULTS/UNASSIGNED:Fourteen SPTCs (19%) completed the survey. Most respondents were prepared to provide intubation/mechanical ventilation (79%), pharmacologic cardioversion (79%), renal replacement therapy (71%), and defibrillation (71%) to suspected and confirmed VHF patients. Few were ready to provide cricothyrotomy (36%), extracorporeal membranous oxygenation (ECMO) (29%), or code status (14%). Factors impacting institutions' ability to provide critical care to a VHF patient included staff safety (71%) and clinical futility (50%). Less than half (36%) reported that the COVID-19 pandemic positively affected their facility's ability to care for VHF patients, while 21% indicated the pandemic prompted their facility to be better prepared to care for a VHF patient. CONCLUSIONS/UNASSIGNED:Most responding SPTCs reported capability for critical care interventions, although fewer had policies governing code status, ECMO, and cricothyrotomy. Institutions were less prepared to manage a VHF patient after the COVID-19 pandemic, highlighting challenges such as staff turnover and less support for training and equipment maintenance. Given that special pathogen outbreaks continue to occur globally, governments and healthcare institutions should institute measures to recruit, support, and retain staff to ensure critical care readiness for special pathogen patients.

Severe mpox has been observed in people with advanced human immunodeficiency virus (HIV). We describe clinical outcomes of 13 patients with advanced HIV (CD4 <200 cells/μL), severe mpox, and multiorgan involvement. Despite extended tecovirimat courses and additional agents, including vaccinia immune globulin, cidofovir, and brincidofovir, this group experienced prolonged hospitalizations and high mortality.

BACKGROUND:COVID-19 symptoms vary widely. This retrospective study assessed which of three clinical screening tools-a nursing triage screen (NTS), an ED review of systems (ROS) performed by physicians and physician assistants and a standardised ED attending (ie, consultant) physician COVID-19 probability assessment (PA)-best identified patients with COVID-19 on a subsequent reverse transcription PCR (RT-PCR) confirmation. METHODS:All patients admitted to Boston Medical Center from the ED between 27 April 2020 and 17 May 2020 were included. Sensitivity, specificity and positive predictive value (PPV) and negative predictive value (NPV) were calculated for each method. Logistic regression assessed each tool's performance. RESULTS:The attending physician PA had higher sensitivity (0.62, 95% CI 0.53 to 0.71) than the NTS (0.46, 95% CI 0.37 to 0.56) and higher specificity (0.76, 95% CI 0.72 to 0.80) than the NTS (0.71, 95% CI 0.66 to 0.75) and ED ROS (0.62, 95% CI 0.58 to 0.67). Categorisation as moderate or high probability on the ED physician PA was associated with the highest odds of having COVID-19 in regression analyses (adjusted OR=4.61, 95% CI 3.01 to 7.06). All methods had a low PPV (ranging from 0.26 for the ED ROS to 0.40 for the attending physician PA) and a similar NPV (0.84 for both the NTS and the ED ROS, and 0.89 for the attending physician PA). CONCLUSION/CONCLUSIONS:The ED attending PA had higher sensitivity and specificity than the other two methods, but none was accurate enough to replace a COVID-19 RT-PCR test in a clinical setting where transmission control is crucial. Therefore, we recommend universal COVID-19 testing prior to all admissions.

Although drug reaction with eosinophilia and systemic symptoms (DRESS) is associated with antiretrovirals, there are no published reports of bictegravir-induced DRESS. Bictegravir is recommended as first-line treatment for patients with human immunodeficiency virus (HIV). Recognition of DRESS, its skin manifestations, and potential complications is vital for appropriate care and management of acute HIV.

During the 2022 mpox outbreak, tecovirimat was accessed through an expanded access investigational new drug (EA-IND) protocol. We leveraged a unique public/private hospital partnership in New York City to create a novel infrastructure to navigate the EA-IND's regulatory requirements and rapidly provide tecovirimat to patients.

OBJECTIVE:In response to the 2013-2016 Ebola virus disease outbreak, the US government designated certain healthcare institutions as Ebola treatment centers (ETCs) to better prepare for future emerging infectious disease outbreaks. This study investigated ETC experiences and critical care policies for patients with viral hemorrhagic fever (VHF). DESIGN:A 58-item questionnaire elicited information on policies for 9 critical care interventions, factors that limited care provision, and innovations developed to deliver care. SETTING AND PARTICIPANTS:The questionnaire was sent to 82 ETCs. METHODS:We analyzed ordinal and categorical data pertaining to the ETC characteristics and descriptive data about their policies and perceived challenges. Statistical analyses assessed whether ETCs with experience caring for VHF patients were more likely to have critical care policies than those that did not. RESULTS:Of the 27 ETCs who responded, 17 (63%) were included. Among them, 8 (47%) reported experience caring for persons under investigation or confirmed cases of VHF. Most felt ready to provide intubation, chest compressions, and renal replacement therapy to these patients. The factors most cited for limiting care were staff safety and clinical futility. Innovations developed to better provide care included increased simulation training and alternative technologies for procedures and communication. CONCLUSIONS:There were broad similarities in critical care policies and limitations among institutions. There were several interventions, namely ECMO and cricothyrotomy, which few institutions felt ready to provide. Future studies could identify obstacles to providing these interventions and explore policy changes after increased experience with novel infectious diseases, such as COVID-19.