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:This study evaluates the prognostic utility of the RV/LV diameter ratio in predicting low cardiac index (CI) in patients with acute intermediate-risk PE. METHODS:We conducted a retrospective analysis of 112 patients with acute PE who underwent catheter-based therapies. The RV/LV diameter ratio was measured from standard axial views on computed tomography pulmonary angiogram (CTPA). Multivariable regression models were used to assess the relationship between the RV/LV diameter ratio and invasive hemodynamic parameters. RESULTS:lower cardiac index (p = 0.002). The RV/LV ratio demonstrated moderate sensitivity (64.5 %) and high specificity (84.2 %) for predicting low cardiac index. CONCLUSION/CONCLUSIONS:The RV/LV diameter ratio offers real-time risk stratification and is a predictor of low cardiac index in patients with acute PE.

BACKGROUND/UNASSIGNED:Among patients with intermediate-risk pulmonary embolism undergoing mechanical thrombectomy, the mean change in cardiac index (CI) is modest. We sought to identify variables associated with a hemodynamic super-response or a CI increase of ≥25% postthrombectomy. METHODS/UNASSIGNED:This was a single-center retrospective study including patients with intermediate-risk pulmonary embolism undergoing mechanical thrombectomy with pulmonary artery catheter-derived hemodynamic indices obtained preprocedure and postprocedure. RESULTS/UNASSIGNED:was associated with a hemodynamic super-response (odds ratio, 3.76 [95% CI, 1.09-13.0]). CONCLUSIONS/UNASSIGNED:Patients with intermediate-risk pulmonary embolism with the more severe hemodynamic derangements had the greatest improvement in CI post thrombectomy. This group can be identified with commonly available noninvasive indices of right ventricular dysfunction.

NYC Health + Hospitals/Bellevue Hospital (Bellevue) conducts quarterly drills to test the readiness and preparedness of its special pathogen program. As a Regional Emerging Special Pathogen Treatment Center, Bellevue maintains a state of readiness to respond to patients infected with highly infectious pathogens. On March 29, 2024, Bellevue conducted a no-notice drill to simulate the arrival of a pediatric patient suspected of a viral hemorrhagic fever (VHF). Notification of the special pathogens unit (SPU) activation for a suspected VHF patient was communicated to Bellevue supervisors and leadership. Once responders arrived at their respective reporting stations, they were informed that this was a drill and instructed to read through their role-specific Roles & Responsibilities sheet. All respondents reported to assume their role in the SPU activation within the expected time frame. The cost savings of running this drill, as opposed to a full unit activation, was estimated to be nearly USD 2,000. Following the exercise, participants were offered to complete an anonymous survey assessing their perceptions of the drill and readiness for SPU activation. Key findings were that while most staff felt adequately prepared and understood their roles and responsibilities, suggestions for improvement included more frequent training sessions. This study underscores the importance of regular preparedness exercises to maintain SPU readiness. Insights gained from this drill can inform future training models, enhance the effectiveness of communication strategies during real-world activations, and can be replicated to improve the special pathogen preparedness of healthcare institutions across the United States, regardless of resource availability.

New York City has been the epicenter of multiple recent infectious disease outbreaks, including COVID-19 and mpox, due to its position as one of the largest international travel hubs in the United States. In response to the imperative need to transport patients to specialized biocontainment units during high-consequence infectious disease outbreaks, the Health and Human Services Region 2 Regional Emerging Special Pathogen Treatment Center at New York City Health + Hospitals/Bellevue and the NYC Department of Health and Mental Hygiene spearheaded a comprehensive patient transport system. Informed by real-world experiences, quarterly drills, and regional partner engagement, the updated Region 2 patient transport concept of operations (CONOPS) ensures safe and seamless patient transfers. This article elucidates key components of the patient transport CONOPS, the multifaceted partner engagement approach used to develop it, and the collaborative workshop that fine-tuned the plan. Organizational skills, partner engagement, and adaptability were all necessary for refining and operationalizing a robust patient transport CONOPS. The finalization of this plan speaks to the collaborative spirit and commitment of regional leaders to ensure the effective management of high-consequence infectious disease outbreaks and the safeguarding of public health within Region 2 and beyond.

BACKGROUND:Patients with intermediate-risk pulmonary embolism (PE) have outcomes worse than uncomplicated ST elevation myocardial infarction. Yet, no large-scale study has compared the outcomes of large-bore mechanical thrombectomy (LBMT) with anticoagulation alone (AC). The aim of this study was to compare the clinical outcomes among patients receiving LBMT vs AC alone. METHODS:This was a two-center retrospective study that included patients with intermediate-risk PE from October 2016 - October 2023 from the institution's Pulmonary Embolism Response Team (PERT) database. The primary outcome was a composite of 30-day mortality, resuscitated cardiac arrest or hemodynamic decompensation. Inverse probability of treatment weighting (IPTW) was used to balance covariates; Kaplan Meir curves and IPTW multivariable Cox regression were used to assess the relationship between treatment groups and outcomes. RESULTS:Of the 273 patients included in the analysis, 192 (70 %) patients received AC alone and 81 (30 %) patients received LBMT and AC. A total of 30 (10.9 %) patients experienced the primary composite outcome over a median follow-up of 30 days. The primary composite outcome was significantly lower in the group that received LBMT compared to those on AC alone (1.2 % vs 15.1 %, log-rank p < 0.001; adjusted HR: 0.02; 95 % CI: 0.002-0.17, p < 0.001) driven by a lower rate of 30-day all-cause mortality (0 % vs 7.3 %, log-rank p = 0.01), resuscitated cardiac arrest (0 % vs 6.8 %, log-rank p = 0.016) and new or worsening hemodynamic instability (4 % vs 11.1 %, log-rank p = 0.007). CONCLUSION/CONCLUSIONS:In this largest cohort to date comparing LBMT versus AC alone in acute intermediate-risk PE, LBMT had a significantly lower rate of the primary composite outcome including a lower rate of all-cause mortality when compared to AC alone. Ongoing randomized trials will test these associations.

Acute respiratory distress syndrome (ARDS) is a heterogeneous group of disease entities that are associated with acute hypoxic respiratory failure and significant morbidity and mortality. With a better understanding and phenotyping of lung injury, novel pathophysiologic mechanisms demonstrate the impact of a patient's excessive spontaneous breathing effort on perpetuating lung injury. Patient self-inflicted lung injury (P-SILI) is a recently identified phenomenon that delves into the impact of spontaneous breathing on respiratory mechanics in patients with lung injury. While the studies are hypothesis-generating and have been demonstrated in animal and human studies, further clinical trials are needed to identify its impact on ARDS management. The purpose of this review article is to highlight the physiologic mechanisms of P-SILI, novel tools and methods to detect P-SILI, and to review the current literature on non-invasive and invasive respiratory management in patients with ARDS.

BACKGROUND:The relationship between syncope and invasive hemodynamics in patients with pulmonary embolism (PE) remains unknown. The objective of this study was to assess the ability of syncope, as a single clinical variable, to predict a low cardiac index in patients with acute PE. METHODS:) in patients with acute intermediate- high risk PE. Secondary outcomes included 30-day mortality, hemodynamic instability, 90-day readmission rates, other invasive hemodynamic parameters, intensive care unit (ICU) length of stay (LOS), and hospital LOS. Regression analyses were used to evaluate the association between cardiac index and syncope. RESULTS:A total of 132 patients (86% intermediate- and 14% high-risk) were included in the study, with 27 (20%) presenting with syncope. Among the 114 intermediate-risk patients, 24 (21%) presented with syncope. In all-comers, there was no significant difference between groups at baseline. Within the intermediate-only subgroup, there were no significant differences between groups at baseline, except that the syncope group was older (62.6 ± 14.9 vs. 56.1 ± 13.9, p=0.048, Table 2) and had significantly higher troponin elevation at presentation (684.3 ± 1361.8ng/L vs. 195.6 ± 278.1ng/L, p=0.003, Table 2). In all-comers, there was no difference in rates of low cardiac index (63% vs. 59%, p=0.71) or mPAP (33.9 ± 8.6 vs. 32.7 ± 9.6 mm Hg, p=0.57) between patients who presented with and without syncope. Similarly, among intermediate-risk patients, there was also no difference in the rates of low cardiac index (67% vs. 57%, p=0.38) or mPAP (34.0 ± 9.2 vs. 33.1 ± 9.8 mmHg, p=0.69) between patients with and without syncope. There was no difference in clinical outcomes between those who presented with and without syncope. CONCLUSION/CONCLUSIONS:In conclusion, in patients with acute PE, syncope was not associated with a low cardiac index or higher mPAP.

BACKGROUND/UNASSIGNED:The aim of this study was to examine the impact of early versus delayed catheter-based therapies (CBTs) on clinical outcomes in patients with acute intermediate-risk pulmonary embolism (PE). METHODS/UNASSIGNED:This retrospective cohort study analyzed data from 2 academic centers involving patients with intermediate-risk PE from January 2020 to January 2024. Patients were divided into early (<12 hours) and delayed CBT (≥12 hours) groups. The primary outcome was a composite of 30-day mortality, resuscitated cardiac arrest, hemodynamic instability, and 90-day readmission. Secondary outcomes included a composite of 30-day mortality, resuscitated cardiac arrest, and hemodynamic instability. Inverse probability of treatment weighting was used to balance covariates. RESULTS/UNASSIGNED:=0.046). When patients were stratified by timing of CBT (early/late) and the composite PE shock score (high ≥3; low <3), all 16 patients who experienced the primary composite outcome had a high composite PE shock score, with 14/16 (87.5%) having a high composite PE shock score and delayed intervention. CONCLUSIONS/UNASSIGNED:Early CBT was associated with improved clinical outcomes in patients with acute intermediate-risk PE. The composite PE shock score may help identify patients who will benefit from early CBT. Further prospective studies are needed to validate these findings.