Faculty Bibliography

BACKGROUND:Previous work has demonstrated that patients experience functional decline at 1-3 months post-discharge after COVID-19 hospitalization. OBJECTIVE:To determine whether symptoms persist further or improve over time, we followed patients discharged after hospitalization for severe COVID-19 to characterize their overall health status and their physical and mental health at 6 months post-hospital discharge. DESIGN/METHODS:Prospective observational cohort study. PARTICIPANTS/METHODS:Patients ≥ 18 years hospitalized for COVID-19 at a single health system, who required at minimum 6 l of supplemental oxygen during admission, had intact baseline functional status, and were discharged alive. MAIN MEASURES/METHODS:Overall health status, physical health, mental health, and dyspnea were assessed with validated surveys: the PROMIS® Global Health-10 and PROMIS® Dyspnea Characteristics instruments. KEY RESULTS/RESULTS:Of 152 patients who completed the 1 month post-discharge survey, 126 (83%) completed the 6-month survey. Median age of 6-month respondents was 62; 40% were female. Ninety-three (74%) patients reported that their health had not returned to baseline at 6 months, and endorsed a mean of 7.1 symptoms. Participants' summary t-scores in both the physical health and mental health domains at 6 months (45.2, standard deviation [SD] 9.8; 47.4, SD 9.8, respectively) remained lower than their baseline (physical health 53.7, SD 9.4; mental health 54.2, SD 8.0; p<0.001). Overall, 79 (63%) patients reported shortness of breath within the prior week (median score 2 out of 10 (interquartile range [IQR] 0-5), vs 42 (33%) pre-COVID-19 infection (0, IQR 0-1)). A total of 11/124 (9%) patients without pre-COVID oxygen requirements still needed oxygen 6 months post-hospital discharge. One hundred and seven (85%) were still experiencing fatigue at 6 months post-discharge. CONCLUSIONS:Even 6 months after hospital discharge, the majority of patients report that their health has not returned to normal. Support and treatments to return these patients back to their pre-COVID baseline are urgently needed.

OBJECTIVE:New York City was the epicenter of the outbreak of the 2019 coronavirus disease (COVID-19) pandemic in the United States. As a large, quaternary care medical center, NYU Langone Medical Center was one of many New York medical centers that experienced an unprecedented influx of patients during this time. Clinical leadership effectively identified, oriented, and rapidly deployed a "COVID Army," consisting of non-hospitalist physicians, to meet the needs of the patient influx. We share feedback from our providers on our processes and offer specific recommendations for systems experiencing a similar influx in the current and future pandemics. METHODS:To assess the experiences and perceived readiness of these physicians (n = 183), we distributed a 32-item survey between March and June of 2020. Thematic analyses and response rates were examined to develop results. RESULTS:Responses highlighted varying experiences and attitudes of our frontline physicians during an emerging pandemic. Thematic analyses revealed a series of lessons learned, including the need to (1) provide orientations, (2) clarify roles/workflow, (3) balance team workload, (4) keep teams updated on evolving policies, (5) make team members feel valued, and (6) ensure they have necessary tools available. CONCLUSIONS:Lessons from our deployment and assessment are scalable at other institutions.

BACKGROUND:Little is known about long-term recovery from severe COVID-19 disease. Here, we characterize overall health, physical health, and mental health of patients 1 month after discharge for severe COVID-19. METHODS:This was a prospective single health system observational cohort study of patients ≥ 18 years hospitalized with laboratory-confirmed COVID-19 disease who required at least 6 l of oxygen during admission, had intact baseline cognitive and functional status, and were discharged alive. Participants were enrolled between 30 and 40 days after discharge. Outcomes were elicited through validated survey instruments: the PROMIS® Dyspnea Characteristics and PROMIS® Global Health-10. RESULTS:A total of 161 patients (40.6% of eligible) were enrolled; 152 (38.3%) completed the survey. Median age was 62 years (interquartile range [IQR], 50-67); 57 (37%) were female. Overall, 113/152 (74%) participants reported shortness of breath within the prior week (median score 3 out of 10 [IQR 0-5]), vs 47/152 (31%) pre-COVID-19 infection (0, IQR 0-1), p < 0.001. Participants also rated their physical health and mental health as worse in their post-COVID state (43.8, standard deviation 9.3; mental health 47.3, SD 9.3) compared to their pre-COVID state, (54.3, SD 9.3; 54.3, SD 7.8, respectively), both p < 0.001. Physical and mental health means in the general US population are 50 (SD 10). A total of 52/148 (35.1%) patients without pre-COVID oxygen requirements needed home oxygen after hospital discharge; 20/148 (13.5%) reported still using oxygen at time of survey. CONCLUSIONS:Patients with severe COVID-19 disease typically experience sequelae affecting their respiratory status, physical health, and mental health for at least several weeks after hospital discharge.

PURPOSE/OBJECTIVE:With clinical volumes decreased, radiologists volunteered to participate virtually in daily clinical rounds and provide communication between frontline physicians and patients with coronavirus disease 2019 (COVID-19) and their families affected by restrictive hospital visitation policies. The purpose of this survey-based assessment was to demonstrate the beneficial effects of radiologist engagement during this pandemic and potentially in future crises if needed. METHODS:After the program's completion, a survey consisting of 13 multiple-choice and open-ended questions was distributed to the 69 radiologists who volunteered for a minimum of 7 days. The survey focused on how the experience would change future practice, the nature of interaction with medical students, and the motivation for volunteering. The electronic medical record system identified the patients who tested positive for or were suspected of having COVID-19 and the number of notes documenting family communication. RESULTS:In all, 69 radiologists signed or cosigned 7,027 notes. Of the 69 radiologists, 60 (87.0%) responded to the survey. All found the experience increased their understanding of COVID-19 and its effect on the health care system. Overall, 59.6% agreed that participation would result in future change in communication with patients and their families. Nearly all (98.1%) who worked with medical students agreed that their experience with medical students was rewarding. A majority (82.7%) chose to participate as a way to provide service to the patient population. CONCLUSION/CONCLUSIONS:This program provided support to frontline inpatient teams while also positively affecting the radiologist participants. If a similar situation arises in the future, this communication tool could be redeployed, especially with the collaboration of medical students.

BACKGROUND: New York City was the epicenter of the COVID pandemic in the US during early 2020. NYU Langone Medical Center was one of many New York medical centers that experienced an unprecedented influx of patients. During the onset of the pandemic, clinic leadership identified, oriented, and rapidly deployed a COVID Army, consisting of non-hospitalist physicians, to meet the needs of this patient influx. Orientation and training included an hour-long session with an emphasis on the inpatient electronic medical record system and a plan for at the elbow assistance from senior hospitalists. Here, we share feedback from our providers on our capacity building process and use information gathered to offer specific lessons learned in planning for workforce mobilization.
METHOD(S): A 32-item survey was distributed from March-June of 2020 in order to assess the experiences of these ancillary physicians, all of which were NYU Langone providers. Items included a mix of Likert and open-ended questions on demographics and attitudes toward experiences on the COVID team.
RESULT(S): All 272 volunteers received a survey. 67% (n=183) responded. 84 (46%) were from the Department of Medicine, the remainder were primarily from surgical, pediatrics or obstetrics/gynecology. Respondents worked in combination ambulatory/inpatient practices (n=94; 52%) or outpatient only (n=85; 47%) (Mean years in practice: 7.18). 76% felt that the number of patients they were in charge of felt Just Right (average: 7). 10% rated the experience as challenging (n=17). On their perception of support and training, 94% and 63% rated the support and training they received as somewhat or very effective, respectively. 89% (n=99) and 96% (n=107) of supplemental attendings felt valued and valuable to their team, respectively. 87% of respondents identified as being willing to volunteer again. In review of open-ended feedback, we identified a series of themes surrounding areas for improvement. These include the need to 1) invest time into orientations, including training on EHR use, (2) clarify roles and workflow within each team up front, (3) balance team workload if possible, (4) keep teams updated on evolving policies and recommendations, (5) make team members feel valued and supported, and (6) ensure they have the right tools available.
CONCLUSION(S): Given what we have learned from our survey, the continued waxing and waning of community infection, and the unknown length and extent of the COVID pandemic, we recommend providing transparent leadership, frequent communication, and an educational series to ensure everyone is learning together. In addition, clarity is essential, and it is important to be specific in defining the exact roles of ancillary physicians. It is our hope that the lessons learned from our needs assessment can be applied to other hospitals currently in the throes of a surge of COVID inpatients. LEARNING OBJECTIVE #1: Identify best practices for preparing an ancillary workforce for patient surge. LEARNING OBJECTIVE #2: Understand tools for quality patient care

BACKGROUND:Little is known about long-term recovery from severe COVID-19 disease. Here, we characterize overall health, physical health and mental health of patients one month after discharge for severe COVID-19. METHODS:This was a prospective single health system observational cohort study of patients ≥18 years hospitalized with laboratory-confirmed COVID-19 disease who required at least 6 liters of oxygen during admission, had intact baseline cognitive and functional status and were discharged alive. Participants were enrolled between 30 and 40 days after discharge. Outcomes were elicited through validated survey instruments: the PROMIS Dyspnea Characteristics and PROMIS Global Health-10. RESULTS:A total of 161 patients (40.6% of eligible) were enrolled; 152 (38.3%) completed the survey. Median age was 62 years (interquartile range [IQR], 50-67); 57 (37%) were female. Overall, 113/152 (74%) participants reported shortness of breath within the prior week (median score 3 out of 10 [IQR 0-5]), vs. 47/152 (31%) pre-COVID-19 infection (0, IQR 0-1), p<0.001. Participants also rated their physical health and mental health as worse in their post-COVID state (43.8, standard deviation 9.3; mental health 47.3, SD 9.3) compared to their pre-COVID state, (54.3, SD 9.3; 54.3, SD 7.8, respectively), both p <0.001. A total of 52/148 (35.1%) patients without pre-COVID oxygen requirements needed home oxygen after hospital discharge; 20/148 (13.5%) reported still using oxygen at time of survey. CONCLUSIONS:Patients with severe COVID-19 disease typically experience sequelae affecting their respiratory status, physical health and mental health for at least several weeks after hospital discharge.

BACKGROUND AND PURPOSE/OBJECTIVE:Patients with the Coronavirus Disease of 2019 (COVID-19) are at increased risk for thrombotic events and mortality. Various anticoagulation regimens are now being considered for these patients. Anticoagulation is known to increase the risk for adverse bleeding events, of which intracranial hemorrhage (ICH) is one of the most feared. We present a retrospective study of 33 patients positive for COVID-19 with neuroimaging-documented ICH and examine anticoagulation use in this population. METHODS:Patients over the age of 18 with confirmed COVID-19 and radiographic evidence of ICH were included in this study. Evidence of hemorrhage was confirmed and categorized by a fellowship trained neuroradiologist. Electronic health records were analyzed for patient information including demographic data, medical history, hospital course, laboratory values, and medications. RESULTS:We identified 33 COVID-19 positive patients with ICH, mean age 61.6 years (range 37-83 years), 21.2% of whom were female. Parenchymal hemorrhages with mass effect and herniation occurred in 5 (15.2%) patients, with a 100% mortality rate. Of the remaining 28 patients with ICH, 7 (25%) had punctate hemorrhages, 17 (60.7%) had small- moderate size hemorrhages, and 4 (14.3%) had a large single site of hemorrhage without evidence of herniation. Almost all patients received either therapeutic dose anticoagulation (in 22 [66.7%] patients) or prophylactic dose (in 3 [9.1] patients) prior to ICH discovery. CONCLUSIONS:Anticoagulation therapy may be considered in patients with COVID-19 though the risk of ICH should be taken into account when developing a treatment regimen.

OBJECTIVE:To investigate the incidence and spectrum of neuroimaging findings and their prognostic role in hospitalized COVID-19 patients in New York City. METHODS:This is a retrospective cohort study of 3218 COVID-19 confirmed patients admitted to a major healthcare system (three hospitals) in New York City between March 1, 2020 and April 13, 2020. Clinical data were extracted from electronic medical records, and particularly data of all neurological symptoms were extracted from the imaging reports. Four neuroradiologists evaluated all neuroimaging studies for acute neuroimaging findings related to COVID-19. RESULTS:14.1% of admitted COVID-19 patients had neuroimaging and this accounted for only 5.5% of the total imaging studies. Acute stroke was the most common finding on neuro-imaging, seen in 92.5% of patients with positive neuro-imaging studies, and present in 1.1% of hospitalized COVID-19 patients. Patients with acute large ischemic and hemorrhagic stroke had much higher mortality risk adjusted for age, BMI and hypertension compared to those COVID-19 patients without neuroimaging. (Odds Ratio 6.02 by LR; Hazard Ratio 2.28 by CRR). CONCLUSIONS:Our study demonstrates acute stroke is the most common neuroimaging finding among hospitalized COVID-19 patients. Detection of an acute stroke is a strong prognostic marker of poor outcome. Our study also highlights the fact there is limited use of neuroimaging in these patients due to multiple logistical constraints.

Background/Purpose: Mental health problems are common and often untreated in youth with rheumatologic disease, yet their relationship with disease features is poorly understood. We engaged patients and parents on the research team to identify cross-cutting disease factors impacting mental health in this population.
Method(s): An anonymous cross-sectional online survey examined mental health experiences of patients with juvenile arthritis, juvenile dermatomyositis, or systemic lupus erythematosus. Youth ages 14-24 years and parents of youth 8-24 years were eligible. The survey was developed with patient and parent advisors, the Childhood Arthritis & Rheumatology Research Alliance (CARRA), and the Patients, Advocates, and Rheumatology Teams Network for Research and Service (PARTNERS). Participants were recruited through the Arthritis Foundation, Lupus Foundation of America, and Cure JM Foundation. Primary outcome was the presence of any clinician or self-diagnosed mental health problem. Exposures of interest included several cross-cutting disease factors: disease duration, active disease status, current steroid medication, history of disease flare following remission, and appearance-altering comorbidities (psoriasis, stretch marks, alopecia, skin ulceration, visible scarring). We used logistic regression models to examine the association between any clinician or self-diagnosed mental health problems and disease factors for the combined youth/parent sample, and for youth and parents separately. Secondarily, we examined results by mental health problem (depression, anxiety, self-harm/ suicidal ideation). Alpha values < .05 were considered significant.
Result(s): See Table 1 for sample characteristics. 447 respondents included 123 youth and 324 parents; they were not required to be dyads. Combining youth and parent responses, 210 had juvenile arthritis, 173 had juvenile dermatomyositis, and 64 had systemic lupus erythematosus. Those with and without mental health problems were comparable on many demographic and disease factors, although patients with appearance altering comorbidities were more likely to report mental health problems. Rates of clinician and self-diagnosed depression, anxiety, suicidal thoughts, and self-harm are shown in Figure 1. Adjusted logistic regression models (Table 2) indicate that having appearance altering comorbidities predicted the presence of a mental health problem in the combined youth/parent sample and in the parent-only sample. In the combined sample, appearance altering comorbidities also predicted depression and anxiety problems, whereas history of flare following remission predicted reported suicidal ideation or self-harm. Within the youth responses, there was a trend for depression to be more likely among those taking steroids (p=.053).
Conclusion(s): Certain cross-cutting rheumatologic disease factors such as appearance-altering comorbidities are predictive of mental health problems such as depression or anxiety. These findings are helpful for identifying targets for mental health screening in youth with rheumatologic disease, and should be addressed in screening recommendations.(Figure Presented)