National Patterns of Hospital Admission Versus Home Recovery Following Mastectomy for Breast Cancer.

BACKGROUND: We examined national patterns of care and perioperative outcomes for women after mastectomy, comparing home recovery (HR) with hospital admission. PATIENTS AND METHODS: Using Martketscan data (2017-2019), women ≥ 18 years old who underwent mastectomy ± reconstruction were identified and classified as either home recovery (same calendar day discharge) or hospital admission (stays > 1 calendar day). Comorbidities and receipt of chemo/immunotherapy 6 months prior to surgery and post-surgical 30-day complications were measured. Logistic regression calculated the odds of any complication by encounter type, adjusting for age, accompanying lymph node (LN) procedure, reconstruction, neoadjuvant chemo- and/or immunotherapy, and select comorbidities. RESULTS: Of 11,789 mastectomy encounters (N = 11,659 women), 4751 (40%) cases utilized HR while 7038 (60%) had hospital admission. HR patients were older (53.6 years old vs. 51.8 years old) with lower rates of reconstruction (60.2 vs. 74.5%, p < 0.001). Rates of neoadjuvant chemotherapy (19.6 vs. 20.9%, p = 0.099) and immunotherapy (3.6 vs. 3.9%, p = 0.445) were similar between groups. Complication rates were lower among HR patients with fewer postoperative hematomas (0.6 vs. 1.3%, p < 0.001) and decreased wound complications (8.5 vs. 9.8%, p = 0.019). In a multivariable analysis, the odds of any complication were approximately 20% lower for HR patients compared with admission patients (aOR 0.81, 95% CI 0.72-0.91, p < 0.001). Unplanned emergency room visits were similar between groups (6.7 vs. 7.2%, p = 0.374); yet fewer hospital re-admissions (2.5 vs. 3.5%, p = 0.003) occurred in women recovering at home. CONCLUSION: HR is a safe option compared with in-hospital admission for clinically appropriate women after mastectomy as they are less likely to experience postoperative complications, emergency department (ED) visits, or hospitalization.

By Any Other Name: Bowel Dysfunction After Proctectomy for Cancer and Its Predictive Factors in Administrative Databases.

INTRODUCTION: Diagnosis, outcomes, and costs of care associated with bowel dysfunction after proctectomy for cancer remain underexplored in population-based studies. The lack of administrative coding for bowel dysfunction or low anterior resection syndrome has historically limited secondary data set outcomes analysis. The purpose of this study was to identify a bowel dysfunction phenotype in administrative claims data and characterize its prevalence, predictive factors, and costs. MATERIALS AND METHODS: Patients were identified with employer-sponsored commercial insurance (MarketScan research databases) undergoing proctectomy for cancer for a retrospective cohort study. Bowel dysfunction was defined as any patient with diagnostic codes for diarrhea, constipation, incontinence, pelvic floor diagnostic testing, or rehabilitative procedures that occurred in the 18 mo to follow surgery. We performed Poisson regression to identify statistically significant covariates of bowel dysfunction occurrence following low anterior resection. A secondary comparative analysis was also performed of total costs of healthcare utilization following gastrointestinal continuity. RESULTS: 6426 proctectomy patients were identified, out of which 2131 had surgery for cancer. 847 patients undergoing proctectomy for cancer (39.7%) experienced bowel dysfunction during 18 mo of follow-up. The most common diagnoses were constipation (53.5%) and diarrhea (40.3%). Diagnostic procedures and rehabilitative procedures were performed in only 29.8% of those with symptoms. Neoadjuvant chemotherapy administration with radiation (incidence rate ratio = 1.23, 95% CI: 1.01-1.51) and without (incidence rate ratio = 1.20, 95% CI: 1.01-1.42) remained associated with postoperative bowel dysfunction when controlling for other factors. Chemoradiation therapy alone was not associated with bowel dysfunction. The median total follow-up costs with bowel dysfunction were $30,769 greater (P < 0.001). CONCLUSIONS: More than one-third of patients have symptomatic bowel dysfunction within 18 mo after restored continuity, with multiagent chemotherapy being the strongest independent predictor. Bowel dysfunction is associated with more than twice healthcare costs postop.

Diverticulitis in Older Adults: Is Cognitive Impairment Associated With Outcomes?

INTRODUCTION: Older age is associated with increased prevalence of both diverticulitis and cognitive impairment. The association between cognitive impairment and outcomes among older adults presenting to the emergency department (ED) for diverticulitis is unknown. METHODS: Adults aged ≥65 y presenting to an ED with a primary diagnosis of colonic diverticulitis were identified using the Nationwide Emergency Department Sample (2016-2019) and stratified by cognitive impairment status in this retrospective cohort study. Multivariable Poisson regression models adjusted for patient age, sex, Elixhauser Comorbidity Index, primary payer status, and presence of complicated diverticulitis quantified relative risk of a) inpatient admission, b) operative intervention, and c) in-hospital mortality comparing patients with or without a diagnosis code suggestive of cognitive impairment. RESULTS: Among 683,444 older adults with an ED encounter for diverticulitis from 2016 to 2019, there were 468,226 patients with isolated colonic diverticulitis and 26,388 (5.6%) with comorbid cognitive impairment. After adjustment, the risk of inpatient admission for those with cognitive impairment was 18% higher than for those without cognitive impairment (adjusted relative risks [aRR]: 1.18, 95% confidence interval [CI]: 1.17-1.20). Those with cognitive impairment were 34% more likely to undergo colectomy than those without cognitive impairment (aRR: 1.34, 95% CI: 1.24-1.44). Older adults with cognitive impairment had a 32% greater mortality than those without cognitive impairment (aRR: 1.32, 95% CI: 1.05-1.67). CONCLUSIONS: Among older adults presenting for ED care with a primary diagnosis of colonic diverticulitis, individuals with cognitive impairment had higher rates of hospitalization, operative intervention, and in-hospital mortality than those without cognitive impairment.

Arterial Diameter and Percentage of Monocytes are Sex-Dependent Predictors of Early Arteriovenous Fistula Maturation.

BACKGROUND: Arteriovenous fistulae mature less frequently in women than in men, leading to inferior patency and decreased fistula utilization in women. We hypothesized that both anatomic and physiologic sex differences explain reduced maturation. METHODS: The electronic medical records of patients who had a primary arteriovenous fistula created from 2016 to 2021 at a single center were reviewed; sample size was determined using a power calculation. Postoperative ultrasound and laboratory tests were obtained at least 4 weeks after fistula creation. Primary unassisted fistula maturation was determined up to 4 years postprocedure. RESULTS: A total of 28 women and 28 men with a brachial-cephalic fistula were analyzed. The inflow brachial artery diameter was smaller in women than in men, both preoperatively (4.2 ± 0.9 vs. 4.9 ± 1.0 mm, P = 0.008) and postoperatively (4.8 ± 0.8 vs. 5.3 ± 0.9 mm, P = 0.039). Despite similar preoperative brachial artery peak systolic velocity, women had significantly lower postoperative arterial velocity (P = 0.027). Fistula flow was reduced in women, particularly in the midhumerus (747.0 ± 570.4 vs. 1,117.1 ± 471.3 cc/min, P = 0.003). Percentages of neutrophils and lymphocytes were similar among women and men 6 weeks after fistula creation. However, women had reduced monocytes (8.5 ± 2.0 vs. 10.0 ± 2.6%, P = 0.0168). Among 28 men, 24 of 28 (85.7%) achieved unassisted maturation, whereas only 15 of 28 (53.6%) women had fistulae that matured without intervention. Secondary analysis using logistic regression suggested that postoperative arterial diameter was associated with maturation in men, while postoperative monocyte percentage was associated with maturation in women. CONCLUSIONS: Sex differences during arteriovenous fistula maturation are present in arterial diameter and velocity, suggesting that both anatomic and physiologic differences in arterial inflow contribute to sex differences in fistula maturation. In men, postoperative arterial diameter is correlated with maturation, whereas in women, the significantly lower proportion of circulating monocytes suggests a role for the immune response in fistula maturation.

The Impact of Supportive Housing on Liver-Related Outcomes Among Persons With Hepatitis C Virus Infection.

BACKGROUND: Hepatitis C virus (HCV) infection disproportionately impacts people experiencing homelessness. Hepatitis C virus can lead to negative health outcomes, including mortality. We evaluated the impact of a permanent supportive housing (PSH) program (ie, "treatment") on liver-related morbidity and mortality among persons with chronic homelessness and HCV infection. METHODS: We matched records for persons eligible for a New York City PSH program (2007-2014) with Heath Department HCV and Vital Statistics registries and Medicaid claims. Among persons diagnosed with HCV before or 2 years posteligibility, we added stabilized inverse probability of treatment weights to negative binomial regression models to compare rates for liver disease-related emergency department visits and hospitalizations, and hazard ratios for mortality, by program placement 2 and 5 years posteligibility. RESULTS: We identified 1158 of 8783 placed and 1952 of 19 019 unplaced persons with laboratory-confirmed HCV infection. Permanent supportive housing placement was associated with significantly reduced liver-related emergency department visits (adjusted rate ratio [aRR] = 0.76, 95% confidence interval [CI] = .61-.95), hospitalizations (aRR = 0.62, 95% CI = .54-.71), and all-cause (adjusted hazard ratio [aHR] = 0.65, 95% CI = .46-.92) and liver-related mortality (aHR = 0.72, 95% CI = .09-.83) within 2 years. The reduction remained significant for hospitalizations after 5 years. CONCLUSIONS: Placement into PSH was associated with reduced liver-related morbidity and mortality among persons with HCV infection and chronic homelessness.

Detection of Recurrent Hepatitis C Viremia Using Surveillance Data, New York City.

The introduction of direct-acting antivirals for treating hepatitis C virus (HCV) infection has greatly improved cure rates. However, persons with past HCV infection who engage in high-risk behaviors can be reinfected. Surveillance data from the New York City (NYC) Health Department were used to detect and investigate individuals cured during January 2014 to December 2016 who had a subsequent positive RNA test (recurrence) by April 2018. Clinical interpretation of recurrence was obtained using provider interviews and review of medical records available through Regional Health Information Organizations. Among 6938 cured individuals, 209 recurrence events were detected (2.7 per 100 person-years). Investigations were completed for 62 (30%) events. Of 38 investigated events occurring less than 12 months postcure, 17 (45%) were relapses; of 24 events occurring 12 or more months postcure, only one (4%) was a relapse. Understanding the timing, frequency, and clinical interpretation of HCV recurrence will guide HCV prevention and elimination efforts for NYC.

The Hepatitis C Clinical Exchange Network: A Local Health Department Partnership With Acute Care Hospitals to Promote Screening and Treatment of Hepatitis C Virus Infection.

CONTEXT: As of 2015, an estimated 116000 New York City (NYC) residents had chronic hepatitis C, many of them undiagnosed. Although effective medications have been available since 2014 with the advent of direct-acting antivirals, provider-based barriers to treatment remain. The NYC Department of Health and Mental Hygiene (Health Department) coordinated the Hepatitis C Clinical Exchange Network (HepCX) from 2015 to 2019. The main goal of HepCX was to promote hepatitis C screening and treatment by hospital-based providers. PROGRAM: The Health Department recruited hepatitis C champions (Champions) from acute care hospitals (n = 40) to promote improved hepatitis C care at their institutions. The Health Department provided technical assistance for hospitals to improve electronic medical record (EMR) systems and implement reflex RNA testing, coordinated trainings to increase capacity to treat hepatitis C, and distributed dashboards containing facility-specific testing and treatment metrics. IMPLEMENTATION: By the end of the project period (2019), most hospitals (36/40; 90%) reported having a screening alert for baby boomers in their EMR system and 34 (85%) reported performing reflex RNA testing after a positive hepatitis C antibody test. The Health Department coordinated opportunities for Champions to share their work with providers from network hospitals at meetings and webinars and provided clinical education on hepatitis C treatment in partnership with a local nonprofit organization focused on liver health. Facility-specific dashboards were distributed annually to hospital leadership. RNA confirmation testing increased from an average of 57% in 2015 to 85% in 2018. Treatment initiation rates remained similar over 2 years, averaging 39% in 2017 and 38% in 2018. DISCUSSION: HepCX was a multipronged initiative designed to promote hepatitis C testing and treatment initiation among providers at NYC acute care hospitals. Improvements were observed in confirmatory testing rates; however, treatment initiation rates did not change. Further efforts should be targeted to hospitals in need of additional resources for linkage to care and treatment of hepatitis C.

Hepatitis C infection among men who have sex with men living with HIV in New York City, 2000-2015.

OBJECTIVES: To calculate the rate of hepatitis C virus (HCV) among HIV-infected men who have sex with men (MSM) with no reported history of injection drug use (IDU), and to assess whether disparities exist in HIV/HCV coinfection by race/ethnicity and neighbourhood poverty level within this population in New York City. METHODS: HIV-positive men who reported sex with men and did not report IDU at the time of HIV diagnosis, diagnosed through 2015 and alive as of 2000, were matched to people with HCV first reported to the New York City Department of Health and Mental Hygiene between 2000 and 2015. Those with HCV reported before or within 90 days of HIV infection were excluded. A multivariable Cox proportional hazards model was fit to compare the association between HCV diagnosis, race/ethnicity and neighbourhood poverty level. RESULTS: From 2000 to 2015, 54 488 non-IDU MSM were diagnosed with HIV, of whom 2762 (5.1%) were diagnosed with HCV after HIV diagnosis, yielding an overall age-adjusted HCV diagnosis rate of 512 per 100 000 person-years. HIV/HCV coinfection was significantly higher among non-Latino blacks (adjusted HR (aHR)=1.24, 95% CI 1.11 to 1.40) compared with non-Latino whites and among persons living in high-poverty neighbourhoods compared with those in low-poverty neighbourhoods (aHR=1.17, 95% CI 1.01 to 1.35) after stratification by year of HIV diagnosis. CONCLUSION: Disparities in HIV/HCV coinfection among HIV-positive MSM were observed by race/ethnicity and neighbourhood poverty level. Routine HCV screening is recommended for people infected with HIV. People coinfected with HIV and HCV should be linked to HCV care, treated and cured to reduce morbidity and mortality, and to avoid ongoing HCV transmission.

COVID-19 Outbreak - New York City, February 29-June 1, 2020.

New York City (NYC) was an epicenter of the coronavirus disease 2019 (COVID-19) outbreak in the United States during spring 2020 (1). During March-May 2020, approximately 203,000 laboratory-confirmed COVID-19 cases were reported to the NYC Department of Health and Mental Hygiene (DOHMH). To obtain more complete data, DOHMH used supplementary information sources and relied on direct data importation and matching of patient identifiers for data on hospitalization status, the occurrence of death, race/ethnicity, and presence of underlying medical conditions. The highest rates of cases, hospitalizations, and deaths were concentrated in communities of color, high-poverty areas, and among persons aged ≥75 years or with underlying conditions. The crude fatality rate was 9.2% overall and 32.1% among hospitalized patients. Using these data to prevent additional infections among NYC residents during subsequent waves of the pandemic, particularly among those at highest risk for hospitalization and death, is critical. Mitigating COVID-19 transmission among vulnerable groups at high risk for hospitalization and death is an urgent priority. Similar to NYC, other jurisdictions might find the use of supplementary information sources valuable in their efforts to prevent COVID-19 infections.

Development and Validation of Surveillance-Based Algorithms to Estimate Hepatitis C Treatment and Cure in New York City.

CONTEXT: Treatment options for chronic hepatitis C virus (HCV) have improved in recent years. The burden of HCV in New York City (NYC) is high. Measuring treatment and cure among NYC residents with HCV infection will allow the NYC Department of Health and Mental Hygiene (DOHMH) to appropriately plan interventions, allocate resources, and identify disparities to combat the hepatitis C epidemic in NYC. OBJECTIVE: To validate algorithms designed to estimate treatment and cure of HCV using RNA test results reported through routine surveillance. DESIGN: Investigation by NYC DOHMH to determine the true treatment and cure status of HCV-infected individuals using chart review and HCV test data. Treatment and cure status as determined by investigation are compared with the status determined by the algorithms. SETTING: New York City health care facilities. PARTICIPANTS: A total of 250 individuals with HCV reported to the New York City Department of Health and Mental Hygiene (NYC DOHMH) prior to March 2016 randomly selected from 15 health care facilities. MAIN OUTCOME MEASURES: The sensitivity and specificity of the algorithms. RESULTS: Of 235 individuals successfully investigated, 161 (69%) initiated treatment and 96 (41%) achieved cure since the beginning of 2014. The treatment algorithm had a sensitivity of 93.2% (95% confidence interval [CI], 89.2%-97.1%) and a specificity of 83.8% (95% CI, 75.3%-92.2%). The cure algorithm had a sensitivity of 93.8% (95% CI, 88.9%-98.6%) and a specificity of 89.4% (95% CI, 83.5%-95.4%). Applying the algorithms to 68 088 individuals with HCV reported to DOHMH between July 1, 2014, and December 31, 2016, 28 392 (41.7%) received treatment and 16 921 (24.9%) were cured. CONCLUSIONS: The algorithms developed by DOHMH are able to accurately identify HCV treatment and cure using only routinely reported surveillance data. Such algorithms can be used to measure treatment and cure jurisdiction-wide and will be vital for monitoring and addressing HCV. NYC DOHMH will apply these algorithms to surveillance data to monitor treatment and cure rates at city-wide and programmatic levels, and use the algorithms to measure progress towards defined treatment and cure targets for the city.

Hepatocellular Carcinoma and Viral Hepatitis in New York City.

BACKGROUND: The incidence and mortality rate of hepatocellular carcinoma (HCC) are increasing in the United States. Viral hepatitis infection is a primary risk factor for HCC. This study describes the relationship between viral hepatitis and HCC in New York City (NYC). METHODS: Viral hepatitis cases reported to the NYC Department of Health from 1999-2012 were matched to HCC cases diagnosed from 2001 to 2012 and reported to the New York State Cancer Registry. HCC cases were stratified by the presence or absence of viral hepatitis. Demographic characteristics, factors associated with specific causes of death, and survival time were analyzed for all HCC cases. RESULTS: From 2001-2012, a total of 8827 NYC residents had HCC diagnosed; 38.4% had hepatitis C virus (HCV) infection, 17.9% had hepatitis B virus (HBV) infection, and 2.2% had both. Patients with HCC were predominantly men (74.8%), with equal proportions of white non-Hispanic (28.6%) and Hispanic (28.9%) patients. Those with HBV infection were primarily Asian/Pacific Islanders (63.2%). The median survival time after HCC diagnosis for persons with HBV infection was 22.3 months, compared with 13.1 months for persons with HCV infection, and 6.9 months for noninfected persons. The 5-year survival rate was 37.5% for those with HBV infection, 20.0% for those with HCV infection, 29.5% among coinfected individuals, and 16.1% for those with neither infection reported. CONCLUSIONS: In NYC, most persons with HCC have viral hepatitis; the majority of viral hepatitis infections are due to HCV. Survival for persons with HCC differs widely by viral hepatitis status. This study highlights the importance of viral hepatitis prevention and treatment and HCC screening.

Assessing Trends in Chlamydia Positivity and Gonorrhea Incidence and Their Associations With the Incidence of Pelvic Inflammatory Disease and Ectopic Pregnancy in Washington State, 1988-2010.

BACKGROUND: Chlamydia and gonorrhea screening for women is beneficial if it prevents serious reproductive sequelae, such as pelvic inflammatory disease (PID) and ectopic pregnancy (EP). We assessed trends in PID and EP among women in Washington and their association with gonorrhea incidence and chlamydia positivity in a screened population of women over a 23 year period. METHODS: Using data on chlamydia positivity from the Infertility Prevention Project, gonorrhea incidence from state surveillance, and PID and EP hospitalizations from hospital discharge records, we assessed trends in each condition over time. In addition, we estimated total incidence of PID and EP by incorporating information on outpatient-treated cases in alternative populations using a Bayesian approach that accounted for uncertainty in the estimates. We assessed associations between each infection and PID/EP using a linear regression model that accounts for year-to-year correlation in data points. RESULTS: We observed substantial declines in both infections and in each outcome over time. For every 2% decrease in chlamydia positivity, there was a 35.7/100,000 decrease in estimated total PID incidence (P = 0.058) and 184.4/100,000 decrease in estimated total EP (P = 0.149). For every 32/100,000 decline in gonorrhea incidence, there was a 16.5/100,000 decrease in total PID (P = 0.292) and 159.8/100,000 decrease in total EP (P = 0.020). The associations with inpatient PID and EP were highly significant for both chlamydia and gonorrhea. CONCLUSIONS: These ecological data note concurrent and substantial declines in chlamydia positivity and gonorrhea incidence, and in PID and EP incidence in Washington from 1988 to 2010 during a time when widespread chlamydia screening was ongoing.

Notes from the Field: Fungal Bloodstream Infections Associated with a Compounded Intravenous Medication at an Outpatient Oncology Clinic - New York City, 2016.

On May 24, 2016, the New York City Department of Health and Mental Hygiene notified CDC of two cases of Exophiala dermatitidis bloodstream infections among patients with malignancies who had received care from a single physician at an outpatient oncology facility (clinic A). Review of January 1-May 31, 2016 microbiology records identified E. dermatitidis bloodstream infections in two additional patients who also had received care at clinic A. All four patients had implanted vascular access ports and had received intravenous (IV) medications, including a compounded IV flush solution containing saline, heparin, vancomycin, and ceftazidime, compounded and administered at clinic A.

For whom the bell tolls: assessing the incremental costs associated with failure to rescue after elective colorectal surgery.

BACKGROUND: Failure to rescue after elective surgery is associated with increased healthcare costs. These costs are poorly understood and have not been reported for colorectal surgery. This study aimed to assess the incremental costs of failure to rescue after elective colorectal surgery. METHODS: This was a retrospective study of adult patients identified in the National Inpatient Sample from 2016 to 2019 who underwent an elective colectomy or proctectomy. Patients were stratified into 4 groups: uneventful recovery, successfully rescued, failure to rescue, and died without rescue attempts. "Rescue" was defined as admissions with ≥1 procedure code ≥1 day after the initial procedure. The primary outcome was total admission costs. RESULTS: Of 451,490 admissions for elective colorectal resection, 94.6% had an uneventful recovery, 4.8% were successfully rescued, 0.4% were failure to rescue, and 0.3% died without rescue attempts. The median total hospital cost for the uneventful recovery cohort was $16,751 (IQR, $12,611-$23,116), for the successfully rescued cohort was $42,295 (IQR, $27,959-$67,077), for the failure-to-rescue cohort was $53,182 (IQR, $30,852-$95,615), and for the died without attempted rescue cohort was $29,296 (IQR, $19,812-$45,919). When comparing cost quantiles by regression analysis, failure-to-rescue patients had significantly higher costs than the successfully rescued patients for the last 3 quantiles (fifth quantile [90th percentile], $163,963 vs $106,521; P < .001). CONCLUSION: Across a nationally representative cohort, the median total hospital costs for patients who failed to be rescued were $10,887 more than for those who were successfully rescued. These findings emphasize the importance of shared decision making and medical futility and highlight opportunities for resource optimization after postoperative complications.

A common mechanism of clinical HIV-1 resistance to the CCR5 antagonist maraviroc despite divergent resistance levels and lack of common gp120 resistance mutations.

BACKGROUND: The CCR5 antagonist maraviroc (MVC) inhibits human immunodeficiency virus type 1 (HIV-1) entry by altering the CCR5 extracellular loops (ECL), such that the gp120 envelope glycoproteins (Env) no longer recognize CCR5. The mechanisms of HIV-1 resistance to MVC, the only CCR5 antagonist licensed for clinical use are poorly understood, with insights into MVC resistance almost exclusively limited to knowledge obtained from in vitro studies or from studies of resistance to other CCR5 antagonists. To more precisely understand mechanisms of resistance to MVC in vivo, we characterized Envs isolated from 2 subjects who experienced virologic failure on MVC. RESULTS: Envs were cloned from subjects 17 and 24 before commencement of MVC (17-Sens and 24-Sens) and after virologic failure (17-Res and 24-Res). The Envs cloned during virologic failure showed broad divergence in resistance levels, with 17-Res Env exhibiting a relatively high maximal percent inhibition (MPI) of ~90% in NP2-CD4/CCR5 cells and peripheral blood mononuclear cells (PBMC), and 24-Res Env exhibiting a very low MPI of ~0 to 12% in both cell types, indicating relatively "weak" and "strong" resistance, respectively. Resistance mutations were strain-specific and mapped to the gp120 V3 loop. Affinity profiling by the 293-Affinofile assay and mathematical modeling using VERSA (Viral Entry Receptor Sensitivity Analysis) metrics revealed that 17-Res and 24-Res Envs engaged MVC-bound CCR5 inefficiently or very efficiently, respectively. Despite highly divergent phenotypes, and a lack of common gp120 resistance mutations, both resistant Envs exhibited an almost superimposable pattern of dramatically increased reliance on sulfated tyrosine residues in the CCR5 N-terminus, and on histidine residues in the CCR5 ECLs. This altered mechanism of CCR5 engagement rendered both the resistant Envs susceptible to neutralization by a sulfated peptide fragment of the CCR5 N-terminus. CONCLUSIONS: Clinical resistance to MVC may involve divergent Env phenotypes and different genetic alterations in gp120, but the molecular mechanism of resistance of the Envs studied here appears to be related. The increased reliance on sulfated CCR5 N-terminus residues suggests a new avenue to block HIV-1 entry by CCR5 N-terminus sulfopeptidomimetic drugs.

Molecular detection of culture-confirmed bacterial bloodstream infections with limited enrichment time.

Conventional blood culturing using automated instrumentation with phenotypic identification requires a significant amount of time to generate results. This study investigated the speed and accuracy of results generated using PCR and pyrosequencing compared to the time required to obtain Gram stain results and final culture identification for cases of culture-confirmed bloodstream infections. Research and physician-ordered blood cultures were drawn concurrently. Aliquots of the incubating research blood culture fluid were removed hourly between 5 and 8 h, at 24 h, and again at 5 days. DNA was extracted from these 6 time point aliquots and analyzed by PCR and pyrosequencing for bacterial rRNA gene targets. These results were then compared to those of the physician-ordered blood culture. PCR and pyrosequencing accurately identified 92% of all culture-confirmed cases after a mean enrichment time of 5.8 ± 2.9 h. When the time needed to complete sample processing was included for PCR and pyrosequencing protocols, the molecular approach yielded results in 11.8 ± 2.9 h compared to means of 27.9 ± 13.6 h to obtain the Gram stain results and 81.6 ± 24.0 h to generate the final culture-based identification. The molecular approach enabled accurate detection of most bacteria present in incubating blood culture bottles on average about 16 h sooner than Gram stain results became available and approximately 3 days sooner than the phenotypic identification was entered in the Laboratory Information System. If implemented, this more rapid molecular approach could minimize the number of doses of unnecessary or ineffective antibiotics administered to patients.

Palliative Care in a Pandemic: A Multicenter Cohort of Critically Ill Patients with Coronavirus Disease 2019.

Background: Trends in mortality, palliative care, and end-of-life care among critically ill patients with coronavirus disease 2019 (COVID-19) remain underreported. We hypothesized that use of palliative care and end-of-life care would increase over time, because improved understanding of the disease course and prognosis would potentially lead to more frequent use of these services. Patients and Methods: Adult patients with severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2) during pandemic wave one (W1: March 2020 to September 2020) or wave two (W2: October 2020 to June 2021) admitted to an intensive care unit (ICU) in one of six northeastern U.S. hospitals were identified and clinical characteristics obtained. Vaccination data were unavailable. Outcomes of interest included mortality, palliative care consultation, and any end-of-life care (including hospice and comfort care). Results: There were 1,904 critically ill patients with COVID-19: 817 (42.9%) in W1 and 1,087 (57.1%) in W2. Patients received mechanical ventilation more often during W1 than W2 (52.9% vs. 46.3%; p = 0.004), with no difference in ICU or hospital length of stay between waves. Mortality between W1 and W2 was similar (31.2% vs. 30.9%; p = 0.888). There was no difference in use of palliative care or any end-of-life care between waves. Patients who died during W2 versus W1 were more likely to have received both mechanical ventilation (77.1% vs. 67.1%; p = 0.007) and palliative care services (52.1% vs. 41.2%; p = 0.009). However, logistic regression adjusted for demographics, baseline comorbid disease, and clinical characteristics showed no difference in mortality (odds ratio [OR], 1.15; 95% confidence interval [CI], 0.89-1.48), palliative care (OR, 1.08; 95% CI, 0.84-1.40), or any end-of-life care (OR, 1.05; 95% CI, 0.82-1.34) in W2 versus W1. Conclusions: Mortality among critically ill patients with COVID-19 has remained constant across two pandemic waves with no change in use of palliative or end-of-life care.

More problems, more money: Identifying and predicting high-cost rescue after colorectal surgery.

Background: Successful rescue after elective surgery is associated with increased healthcare costs, but costs vary widely. Treating all rescue events the same may overlook targeted opportunities for improvement. The purpose of this study was to predict high-cost rescue after elective colorectal surgery. Methods: We identified adult patients in the National Inpatient Sample (2016-2021) who underwent elective colectomy or proctectomy. Rescued patients were defined as those who underwent additional major procedures. Three groups were stratified: 1) uneventful recovery; 2) Low-cost rescue; 3) High-cost rescue. Multivariable Poisson regression was used to identify preoperative clinical predictors of high-cost versus low-cost rescue. Results: We identified 448,590 elective surgeries, and rescued patients composed 4.8 %(21,635) of the total sample. The median increase in costs in rescued patients was $25,544(p < 0.001). Median total inpatient costs were $95,926 in the most expensive rescued versus $34,811 in the less expensive rescued versus $16,751 in the uneventfully discharged(p < 0.001). When comparing the secondary procedures between the less expensive and most expensive rescued groups, the most expensive had an increased proportion of reoperation (73.4 % versus 53.0 %,p < 0.001). When controlling for other factors and stratification by congestive heart failure due to an interaction effect, a reoperation was independently associated with high-cost rescue (RR with CHF = 3.29,95%CI:2.69-4.04; RR without CHF = 2.29,95%CI:1.97-2.67). Conclusions: High-cost rescue after colorectal surgery is associated with disproportionately greater healthcare utilization and reoperation. For cost-conscious care, preemptive strategies that reduce reoperation-related complications can be prioritized.

Association Between Time to First RNA-Negative Test Result Among People With Hepatitis C Virus Infection and Homelessness or Testing at a Correctional or Substance Use Treatment Facility, New York City.

OBJECTIVE: Curative treatments for hepatitis C virus (HCV) infection are available, but access and barriers to treatment can delay initiation. We investigated the time to first negative RNA test result among people with HCV infection and examined differences by homeless status and whether people were tested at a correctional facility or substance use treatment facility. METHODS: We used surveillance data to identify New York City residents first reported with HCV infection during January 1, 2015-December 31, 2018, with ≥1 positive RNA test result during January 1, 2015-November 1, 2019. We used Kaplan-Meier survival analysis to determine the time from the first positive RNA test result to the first negative RNA test result, with right-censoring at date of death or November 1, 2019. We determined substance use treatment, incarceration, or homelessness by ordering facility name and address or from patient residential address. RESULTS: Of 13 952 people with an HCV RNA-positive test result first reported during 2015-2018, 6947 (49.8%) subsequently received an RNA-negative test result. Overall, 25% received an RNA-negative test result within 208 (95% CI, 200-216) days and 50% within 902 (95% CI, 841-966) days. Homelessness, incarceration, or substance use treatment was indicated for 4304 (30.9%) people, among whom 25% received an RNA-negative test result within 469 (95% CI, 427-520) days and <50% received an RNA-negative test result during the study period. CONCLUSIONS: Efforts to connect people to treatment should occur soon after diagnosis, especially for people who could benefit from hepatitis C care coordination.