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Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study

Petrilli, Christopher M; Jones, Simon A; Yang, Jie; Rajagopalan, Harish; O'Donnell, Luke; Chernyak, Yelena; Tobin, Katie A; Cerfolio, Robert J; Francois, Fritz; Horwitz, Leora I
OBJECTIVE:To describe outcomes of people admitted to hospital with coronavirus disease 2019 (covid-19) in the United States, and the clinical and laboratory characteristics associated with severity of illness. DESIGN/METHODS:Prospective cohort study. SETTING/METHODS:Single academic medical center in New York City and Long Island. PARTICIPANTS/METHODS:5279 patients with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) infection between 1 March 2020 and 8 April 2020. The final date of follow up was 5 May 2020. MAIN OUTCOME MEASURES/METHODS:Outcomes were admission to hospital, critical illness (intensive care, mechanical ventilation, discharge to hospice care, or death), and discharge to hospice care or death. Predictors included patient characteristics, medical history, vital signs, and laboratory results. Multivariable logistic regression was conducted to identify risk factors for adverse outcomes, and competing risk survival analysis for mortality. RESULTS:Of 11 544 people tested for SARS-Cov-2, 5566 (48.2%) were positive. After exclusions, 5279 were included. 2741 of these 5279 (51.9%) were admitted to hospital, of whom 1904 (69.5%) were discharged alive without hospice care and 665 (24.3%) were discharged to hospice care or died. Of 647 (23.6%) patients requiring mechanical ventilation, 391 (60.4%) died and 170 (26.2%) were extubated or discharged. The strongest risk for hospital admission was associated with age, with an odds ratio of >2 for all age groups older than 44 years and 37.9 (95% confidence interval 26.1 to 56.0) for ages 75 years and older. Other risks were heart failure (4.4, 2.6 to 8.0), male sex (2.8, 2.4 to 3.2), chronic kidney disease (2.6, 1.9 to 3.6), and any increase in body mass index (BMI) (eg, for BMI >40: 2.5, 1.8 to 3.4). The strongest risks for critical illness besides age were associated with heart failure (1.9, 1.4 to 2.5), BMI >40 (1.5, 1.0 to 2.2), and male sex (1.5, 1.3 to 1.8). Admission oxygen saturation of <88% (3.7, 2.8 to 4.8), troponin level >1 (4.8, 2.1 to 10.9), C reactive protein level >200 (5.1, 2.8 to 9.2), and D-dimer level >2500 (3.9, 2.6 to 6.0) were, however, more strongly associated with critical illness than age or comorbidities. Risk of critical illness decreased significantly over the study period. Similar associations were found for mortality alone. CONCLUSIONS:Age and comorbidities were found to be strong predictors of hospital admission and to a lesser extent of critical illness and mortality in people with covid-19; however, impairment of oxygen on admission and markers of inflammation were most strongly associated with critical illness and mortality. Outcomes seem to be improving over time, potentially suggesting improvements in care.
PMID: 32444366
ISSN: 1756-1833
CID: 4447142

Prevalence and Outcomes of D-Dimer Elevation in Hospitalized Patients With COVID-19

Berger, Jeffrey S; Kunichoff, Dennis; Adhikari, Samrachana; Ahuja, Tania; Amoroso, Nancy; Aphinyanaphongs, Yindalon; Cao, Meng; Goldenberg, Ronald; Hindenburg, Alexander; Horowitz, James; Parnia, Sam; Petrilli, Christopher; Reynolds, Harmony; Simon, Emma; Slater, James; Yaghi, Shadi; Yuriditsky, Eugene; Hochman, Judith; Horwitz, Leora I
OBJECTIVE:<0.001). Rates of adverse events increased with the magnitude of D-dimer elevation; individuals with presenting D-dimer >2000 ng/mL had the highest risk of critical illness (66%), thrombotic event (37.8%), acute kidney injury (58.3%), and death (47%). CONCLUSIONS:Abnormal D-dimer was frequently observed at admission with COVID-19 and was associated with higher incidence of critical illness, thrombotic events, acute kidney injury, and death. The optimal management of patients with elevated D-dimer in COVID-19 requires further study.
PMID: 32840379
ISSN: 1524-4636
CID: 4574192

International patient preferences for physician attire: results from cross-sectional studies in four countries across three continents

Houchens, Nathan; Saint, Sanjay; Petrilli, Christopher; Kuhn, Latoya; Ratz, David; De Lott, Lindsey; Zollinger, Marc; Sax, Hugo; Kamata, Kazuhiro; Kuriyama, Akira; Tokuda, Yasuharu; Fumagalli, Carlo; Virgili, Gianni; Fumagalli, Stefano; Chopra, Vineet
OBJECTIVE:The patient-physician relationship impacts patients' experiences and health outcomes. Physician attire is a form of nonverbal communication that influences this relationship. Prior studies examining attire preferences suffered from heterogeneous measurement and limited context. We thus performed a multicentre, cross-sectional study using a standardised survey instrument to compare patient preferences for physician dress in international settings. SETTING:20 hospitals and healthcare practices in Italy, Japan, Switzerland and the USA. PARTICIPANTS:Convenience sample of 9171 adult patients receiving care in academic hospitals, general medicine clinics, specialty clinics and ophthalmology practices. PRIMARY AND SECONDARY OUTCOME MEASURES:The survey was randomised and included photographs of a male or female physician dressed in assorted forms of attire. The primary outcome measure was attire preference, comprised of composite ratings across five domains: how knowledgeable, trustworthy, caring and approachable the physician appeared, and how comfortable the respondent felt. Secondary outcome measures included variation in preferences by country, physician type and respondent characteristics. RESULTS:The highest rated forms of attire differed by country, although each most preferred attire with white coat. Low ratings were conferred on attire extremes (casual and business suit). Preferences were more uniform for certain physician types. For example, among all respondents, scrubs garnered the highest rating for emergency department physicians (44.2%) and surgeons (42.4%). However, attire preferences diverged for primary care and hospital physicians. All types of formal attire were more strongly preferred in the USA than elsewhere. Respondent age influenced preferences in Japan and the USA only. CONCLUSIONS:Patients across a myriad of geographies, settings and demographics harbour specific preferences for physician attire. Some preferences are nearly universal, whereas others vary substantially. As a one-size-fits-all dress policy is unlikely to reflect patient desires and expectations, a tailored approach should be sought that attempts to match attire to clinical context.
PMCID:9535197
PMID: 36192090
ISSN: 2044-6055
CID: 5351452

Initiative to reduce unnecessary routine daily testing of complete blood counts across 11 safety net hospitals

Cho, Hyung J; Israilov, Sigal; Tsega, Surafel; Alaiev, Dan; Talledo, Joseph; Chandra, Komal; Alarcon Manchego, Peter; Zaurova, Milana; Petrilli, Christopher M; Krouss, Mona
OBJECTIVES/OBJECTIVE:National societies recommend against performing routine daily laboratory testing without a specific indication. Unnecessary testing can lead to patient harm, such as hospital-acquired anemia. The objective of this study was to reduce repeat complete blood counts (CBCs) after initial testing. METHODS:This was a quality improvement initiative implemented across 11 safety net hospitals in New York City. A best practice advisory (BPA) was implemented that asked the user to remove a CBC if the last 2 CBCs within 72 hours had normal white blood cell and platelet counts and unchanged hemoglobin levels. The outcome measure was the rate of CBCs per 1000 patient days preintervention (January 8, 2020, to December 22, 2020) to postintervention (December 23, 2020, to December 7, 2021). The process measure was the acceptance rate of the BPA, defined as the number of times the repeat CBC order was removed through the BPA divided by the total number of times the BPA triggered. RESULTS:Across 11 hospitals, repeat CBC testing decreased by 12.3% (73.05 to 64.04 per 1000 patient days, P < .001). Six of the 11 hospitals exhibited statistically significant decreases, ranging from a 10% to 48.9% decrease of repeat CBCs. The overall BPA action rate was 20.0% (24,029 of 119,944 repeat CBCs). CONCLUSIONS:This low-effort, electronic health record-based intervention can effectively reduce unnecessary laboratory testing.
PMID: 38041859
ISSN: 1943-7722
CID: 5616872

Interleukin-1 receptor antagonist gene ( IL1RN ) variants modulate the cytokine release syndrome and mortality of SARS-CoV-2

Attur, Mukundan; Petrilli, Christopher; Adhikari, Samrachana; Iturrate, Eduardo; Li, Xiyue; Tuminello, Stephanie; Hu, Nan; Chakravarti, Aravinda; Beck, David; Abramson, Steven B
OBJECTIVE/UNASSIGNED:, the gene encoding the anti-inflammatory IL-1 receptor antagonist (IL-1Ra), on the cytokine release syndrome and mortality. METHODS/UNASSIGNED:gene were assessed for association with laboratory markers of the cytokine release syndrome (CRS) and mortality. RESULTS/UNASSIGNED:rs419598 CC SNV exhibited lower inflammatory biomarker levels, and was associated with reduced mortality compared to the CT/TT genotype in men (OR 0.49 (0.23 - 1.00); 0.052), with the most pronounced effect observed between the ages of 55-74 [5.5% vs. 18.4%, p<0.001]. CONCLUSION/UNASSIGNED:modulates the COVID-19 cytokine release syndrome via endogenous " anti-inflammatory" mechanisms. SIGNIFICANCE STATEMENT/UNASSIGNED:merits further evaluation in severe SARS-CoV-2 infection.
PMCID:9882468
PMID: 36711766
CID: 5602052

The impact of COVID-19 monoclonal antibodies on clinical outcomes: A retrospective cohort study

Nagler, Arielle R; Horwitz, Leora I; Jones, Simon; Petrilli, Christopher M; Iturrate, Eduardo; Lighter, Jennifer L; Phillips, Michael; Bosworth, Brian P; Polsky, Bruce; Volpicelli, Frank M; Dapkins, Isaac; Viswanathan, Anand; François, Fritz; Kalkut, Gary
DISCLAIMER/CONCLUSIONS:In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE/OBJECTIVE:Despite progress in the treatment of coronavirus disease 2019 (COVID-19), including the development of monoclonal antibodies (mAbs), more clinical data to support the use of mAbs in outpatients with COVID-19 is needed. This study is designed to determine the impact of bamlanivimab, bamlanivimab/etesevimab, or casirivimab/imdevimab on clinical outcomes within 30 days of COVID-19 diagnosis. METHODS:A retrospective cohort study was conducted at a single academic medical center with 3 campuses in Manhattan, Brooklyn, and Long Island, NY. Patients 12 years of age or older who tested positive for COVID-19 or were treated with a COVID-19-specific therapy, including COVID-19 mAb therapies, at the study site between November 24, 2020, and May 15, 2021, were included. The primary outcomes included rates of emergency department (ED) visit, inpatient admission, intensive care unit (ICU) admission, or death within 30 days from the date of COVID-19 diagnosis. RESULTS:A total of 1,344 mAb-treated patients were propensity matched to 1,344 patients with COVID-19 patients who were not treated with mAb therapy. Within 30 days of diagnosis, among the patients who received mAb therapy, 101 (7.5%) presented to the ED and 79 (5.9%) were admitted. Among the patients who did not receive mAb therapy, 165 (12.3%) presented to the ED and 156 (11.6%) were admitted (relative risk [RR], 0.61 [95% CI, 0.50-0.75] and 0.51 [95% CI, 0.40-0.64], respectively). Four mAb patients (0.3%) and 2.64 control patients (0.2%) were admitted to the ICU (RR, 01.51; 95% CI, 0.45-5.09). Six mAb-treated patients (0.4%) and 3.37 controls (0.3%) died and/or were admitted to hospice (RR, 1.61; 95% CI, 0.54-4.83). mAb therapy in ambulatory patients with COVID-19 decreases the risk of ED presentation and hospital admission within 30 days of diagnosis.
PMCID:9619808
PMID: 36242772
ISSN: 1535-2900
CID: 5361302

Interferon pathway lupus risk alleles modulate risk of death from acute COVID-19

Nln, Ilona; Fernandez-Ruiz, Ruth; Muskardin, Theresa L Wampler; Paredes, Jacqueline L; Blazer, Ashira D; Tuminello, Stephanie; Attur, Mukundan; Iturrate, Eduardo; Petrilli, Christopher M; Abramson, Steven B; Chakravarti, Aravinda; Niewold, Timothy B
Type I interferon (IFN) is critical in our defense against viral infections. Increased type I IFN pathway activation is a genetic risk factor for systemic lupus erythematosus (SLE), and a number of common risk alleles contribute to the high IFN trait. We hypothesized that these common gain-of-function IFN pathway alleles may be associated with protection from mortality in acute COVID-19. We studied patients admitted with acute COVID-19 (756 European-American and 398 African-American ancestry). Ancestral backgrounds were analyzed separately, and mortality after acute COVID-19 was the primary outcome. In European-American ancestry, we found that a haplotype of interferon regulatory factor 5 (IRF5) and alleles of protein kinase cGMP-dependent 1 (PRKG1) were associated with mortality from COVID-19. Interestingly, these were much stronger risk factors in younger patients (OR=29.2 for PRKG1 in ages 45-54). Variants in the IRF7 and IRF8 genes were associated with mortality from COVID-19 in African-American subjects, and these genetic effects were more pronounced in older subjects. Combining genetic information with blood biomarker data such as C-reactive protein, troponin, and D-dimer resulted in significantly improved predictive capacity, and in both ancestral backgrounds the risk genotypes were most relevant in those with positive biomarkers (OR for death between 14 and 111 in high risk genetic/biomarker groups). This study confirms the critical role of the IFN pathway in defense against COVID-19 and viral infections, and supports the idea that some common SLE risk alleles exert protective effects in anti-viral immunity. BACKGROUND: We find that a number of IFN pathway lupus risk alleles significantly impact mortality following COVID-19 infection. These data support the idea that type I IFN pathway risk alleles for autoimmune disease may persist in high frequency in modern human populations due to a benefit in our defense against viral infections. TRANSLATIONAL SIGNIFICANCE: We develop multivariate prediction models which combine genetics and known biomarkers of severity to result in greatly improved prediction of mortality in acute COVID-19. The specific associated alleles provide some clues about key points in our defense against COVID-19.
PMID: 35114420
ISSN: 1878-1810
CID: 5153812

Interferon pathway lupus risk alleles modulate risk of death from acute COVID-19

Nln, Ilona; Fernandez-Ruiz, Ruth; Wampler Muskardin, Theresa L; Paredes, Jacqueline L; Blazer, Ashira D; Tuminello, Stephanie; Attur, Mukundan; Iturrate, Eduardo; Petrilli, Christopher M; Abramson, Steven B; Chakravarti, Aravinda; Niewold, Timothy B
Type I interferon (IFN) is critical in our defense against viral infections. Increased type I IFN pathway activation is a genetic risk factor for systemic lupus erythematosus (SLE), and a number of common risk alleles contribute to the high IFN trait. We hypothesized that these common gain-of-function IFN pathway alleles may be associated with protection from mortality in acute COVID-19. We studied patients admitted with acute COVID-19 (756 European-American and 398 African-American ancestry). Ancestral backgrounds were analyzed separately, and mortality after acute COVID-19 was the primary outcome. In European-American ancestry, we found that a haplotype of interferon regulatory factor 5 (IRF5) and alleles of protein kinase cGMP-dependent 1 (PRKG1) were associated with mortality from COVID-19. Interestingly, these were much stronger risk factors in younger patients (OR=29.2 for PRKG1 in ages 45-54). Variants in the IRF7 and IRF8 genes were associated with mortality from COVID-19 in African-American subjects, and these genetic effects were more pronounced in older subjects. Combining genetic information with blood biomarker data such as C-reactive protein, troponin, and D-dimer resulted in significantly improved predictive capacity, and in both ancestral backgrounds the risk genotypes were most relevant in those with positive biomarkers (OR for death between 14 and 111 in high risk genetic/biomarker groups). This study confirms the critical role of the IFN pathway in defense against COVID-19 and viral infections, and supports the idea that some common SLE risk alleles exert protective effects in anti-viral immunity.
PMID: 34751274
ISSN: n/a
CID: 5362212

Prior bariatric surgery in COVID-19-positive patients may be protective

Jenkins, Megan; Maranga, Gabrielle; Wood, G Craig; Petrilli, Christopher M; Fielding, George; Ren-Fielding, Christine
BACKGROUND:Patients infected with novel COVID-19 virus have a spectrum of illnesses ranging from asymptomatic to death. Data have shown that age, sex, and obesity are strongly correlated with poor outcomes in COVID-19-positive patients. Bariatric surgery is the only treatment that provides significant, sustained weight loss in the severely obese. OBJECTIVES/OBJECTIVE:Examine if prior bariatric surgery correlates with increased risk of hospitalization and outcome severity after COVID-19 infection. SETTING/METHODS:test or Fisher's exact test. Additionally, overall length of stay and duration of time in intensive care unit (ICU) were compared using Wilcoxon rank sum test. Conditional logistic regression analyses were done to determine both unadjusted (UOR) and adjusted odds ratios (AOR). RESULTS:(SD = 6.5, P < .0001). There was also less burden of diabetes in the bariatric group (32%) compared with the control group (48%) (P = .0019). Patients with a history of bariatric surgery were less likely to be admitted through the emergency room (UOR = .39, P = .0001), less likely to require a ventilator during the admission (UOR=.42, P = .028), had a shorter length of stay in both the ICU (P = .033) and overall (UOR = .44, P = .0002), and were less likely to be deceased at discharge compared with the control group (OR = .42, P = .028). CONCLUSION/CONCLUSIONS:A history of bariatric surgery significantly decreases the risk of emergency room admission, mechanical ventilation, prolonged ICU stay, and death in patients with COVID-19. Even when adjusted for BMI and the co-morbidities associated with obesity, patients with a history of bariatric surgery still have a significant decrease in the risk of emergency room admission.
PMCID:8349415
PMID: 34642102
ISSN: 1878-7533
CID: 5027132

Gastrostomy tubes in patients with COVID-19: Reduction of in-hospital mortality with a multidisciplinary team-based approach [Meeting Abstract]

Saltiel, J; Lee, B; Tran, J; Kumar, V; Grendell, J; Goodman, A; Petrilli, C; Bosworth, B; Latorre, M
Introduction: Critically-ill patients with COVID-19 often require long-term enteral access due to prolonged ventilator support and slow recovery from neurologic injury. The outcomes of hospitalized patients with SARS-CoV-2 who received gastrostomy tubes (GTs) are unknown and limited guidance exists on how to safely triage GT placement in this population. The Enteral Access Team (EAT) is a multidisciplinary team led by an attending gastroenterologist (GI) hospitalist with advanced practice providers who collaborate with Palliative Care, Geriatrics, Speech-Language Pathology, and Nutrition to reduce unnecessary feeding tube placements at the end-of-life. The EAT reviews the appropriateness of GT placement and triages each case to the indicated procedural service. The EAT's multidisciplinary approach was applied for patients with COVID-19.
Method(s): We performed a retrospective study of 135 hospitalized patients with positive PCR tests for SARS-CoV-2 who received GTs between 3/2020 and 4/2021. The GTs were placed by 3 services (gastroenterology, interventional radiology and surgery) at 3 hospitals within 1 health system in New York. One of the hospitals employed the multidisciplinary EAT approach to its triage of GT placement. Outcomes were compared between the EAT site and control sites where GT placement was decided through direct consultation by the primary team with one of the procedural services.
Result(s): Demographics for the two groups, including overall numbers of COVID-19 admissions, can be seen in Table 1. At the EAT site (n =43) 5% of patients expired prior to discharge following GT placement compared with 25% at the control sites (P <0.05). Patients at the EAT site were older with a mean age of 70 years compared to the control sites with a mean age of 63 years (P=0.01). There was no significant difference in the percentage of COVID-19 patients who received GTs, length-ofstay, or time from gastrostomy to discharge or death. Multivariable analysis showed the odds of in hospital mortality were 10.1 times greater with the standard workflow than with the EAT workflow (OR 10.1, [95% CI: 1.7-60.6], P <0.05).
Conclusion(s): The EAT's novel multidisciplinary team-based approach helps to appropriately select hospitalized patients with SARs-CoV-2 for long-term enteral access leading to reduced in-hospital mortality following GT placement. Additionally, this approach may help to mediate the national shortage of GTs and reduce the risk of exposure to providers involved in GT placement
EMBASE:636472602
ISSN: 1572-0241
CID: 5084322