Factors Associated with Poor Clinical and Microbiologic Outcomes in C. auris Bloodstream Infection: A Multicenter Retrospective Cohort Study.

BACKGROUND: C. auris has become a growing concern worldwide due to increases in incidence of colonization and reports of invasive infections. There are limited data on clinical factors associated with poor outcomes in patients with C. auris bloodstream infection (BSI). METHODS: We assembled a multicenter retrospective cohort of patients with C. auris BSI from two geographics areas in US healthcare settings. We collected data on demographic, clinical, and microbiologic characteristics to describe the cohort and constructed multivariate logistic regression models to understand risk factors for two clinical outcomes, all-cause mortality during facility admission, and blood culture clearance. RESULTS: Our cohort consisted of 187 patients with C. auris BSI (56.1% male, 55.6% age >65 years); 54.6% died by facility discharge and 66.9% (of 142 with available data) experienced blood culture clearance. Pitt bacteremia score at infection onset was associated with mortality (odds-ratio [95% confidence interval]: 1.19 [1.01,1.40] per 1-point increase). Hemodialysis was associated with a reduced odds of microbiologic clearance (0.15 [0.05,0.43]) and with mortality (3.08 [1.27,7.50]). CONCLUSIONS: The Pitt bacteremia score at the onset of C. auris BSI may be a useful tool in identifying patients at risk for mortality. Targeted infection prevention practices in patients receiving hemodialysis may be useful to limit poor outcomes.

Telemedicine and Resource Utilization in Pulmonary Clinic.

BACKGROUND: Telemedicine use increased with the Covid-19 pandemic. The impact of telemedicine on resource use in pulmonary clinics is unknown. METHODS: This retrospective cohort study identified adults with pulmonary clinic visits at the University of Miami Hospital and Clinics (January 2018-December 2021). The primary exposure was telemedicine versus in-person visits. Standard statistics were used to describe the cohort and compare patients stratified by visit type. Multivariable logistic regression models evaluated the association of telemedicine with resource use (primarily, computed tomography [CT] orders placed within 7 days of visit). RESULTS: 21,744 clinic visits were included: 5,480 (25.2%) telemedicine and 16,264 (74.8%) in-person. In both, the majority were < 65-years-old, female, and identified as Hispanic white. Patients seen with telemedicine had increased odds of having CT scans ordered within 7 days (adjusted odds ratio [aOR] 1.34, [95% confidence interval 1.04-1.74]); and decreased odds of chest x-rays (aOR 0.37 [0.23-0.57]). Telemedicine increased odds of contact of any kind with our healthcare system within 30-days (aOR 1.56 [1.29-1.88]) and 90-days (aOR 1.39 [1.17-1.64]). Specifically, telemedicine visits had decreased odds of emergency department visits and hospitalizations (30 days: aOR 0.54 [0.38-0.76]; 90 days: aOR 0.68 [0.52-0.89]), but increased odds of phone calls and electronic health record inbox messages (30 days: aOR 3.44 [2.73-4.35]; 90 days: aOR 3.58 [2.95-4.35]). CONCLUSIONS: Telemedicine was associated with an increased odds of chest CT order with a concomitant decreased odds of chest x-ray order. Increased contact with the healthcare system with telemedicine may represent a larger time burden for outpatient clinicians.

Randomized Controlled Study of Self-Managed Music-Guided Exercise Intervention Following Intensive Care.

BACKGROUND: Patients who are discharged from the intensive care unit (ICU; termed ICU survivors) often experience persistent physical impairment. OBJECTIVE: The aim of this study was to explore the effects of a self-managed, music-guided exercise intervention on physical outcomes and adherence rates among ICU survivors. METHODS: A randomized controlled design was used. Following ICU discharge, participants admitted to the ICU for at least 5 days were randomly assigned to a music group ( n = 13) or an active control group ( n = 13). Activity counts were measured using an Actiwatch, and the physical health score was measured using the Patient-Reported Outcomes Measurement Information System global health subscale. Adherence to exercise was documented daily. Independent t -tests were used for data analysis. RESULTS: Data were analyzed for 26 participants. The mean age was 62.8 ± 13.8 years, 53.8% were male, 65.4% were White, and mean Acute Physiology and Chronic Health Evaluation severity of illness score was 59 ± 23.4. Global health physical scores were significantly higher in the music group than in the active control group. Although not significantly different, music group participants tended to be more active and had higher physical activity and adherence rates compared to those in the active control group. CONCLUSION: A self-managed, music-guided exercise intervention demonstrated positive benefits on physical outcomes. Future clinical trials with a larger sample size should be conducted to examine the effects of this tailored, cost-effective, innovative, self-managed exercise intervention among ICU survivors.

Postcardiac Surgery Euglycemic Diabetic Ketoacidosis in Patients on Sodium-Glucose Cotransporter 2 Inhibitors.

OBJECTIVES: To evaluate sodium-glucose cotransporter 2 inhibitors (SGLT2i) use and complications (euglycemic diabetic ketoacidosis [eDKA] rate, mortality, infection, hospital, and cardiovascular intensive care unit [CVICU] length of stay [LOS]) in patients undergoing cardiac surgery. DESIGN: A retrospective study. SETTING: At an academic university hospital. PARTICIPANTS: Adult patients undergoing cardiac surgery. INTERVENTIONS: SGLT2i use versus no SGLT2i use. MEASUREMENTS AND MAIN RESULTS: The authors evaluated patients undergoing cardiac surgery within 24 hours of hospital admission (between February 2, 2019 to May 26, 2022) for SGLT2i prevalence and eDKA frequency. The outcomes were compared using Wilcoxon rank sum and chi-square testing as appropriate. The cohort included 1,654 patients undergoing cardiac surgery, of whom 53 (3.2%) were prescribed an SGLT2i before surgery; 8 (15.1%) of 53 had eDKA. The authors found no differences between patients with and without SGLT2i use in hospital LOS (median [IQR]: 4.5 [3.5-6.3] v 4.4 [3.4-5.6] days, p = 0.46) or CVICU LOS (median [IQR]: 1.2 [1.0-2.2] v 1.1 [1.0-1.9] days, p = 0.22), 30-day mortality (1.9% v 0.7%, p = 0.31), or sternal infections (0.0% v 0.3%, p = 0.69). Among patients prescribed an SGLT2i, those with and without eDKA had similar hospital LOS (5.1 [4.0-5.8] v 4.4 [3.4-6.3], p = 0.76); however, CVICU LOS was longer in patients with eDKA (2.2 [1.5-2.9] v 1.2 [0.9-2.0], p = 0.042). Mortality (0.0% v 2.2%, p = 0.67) and wound infections (0.0% v 0.0%, p > 0.99) were similarly rare. CONCLUSIONS: Postoperative eDKA occurred in 15% of patients on an SGLT2i prior to cardiac surgery, and was associated with longer CVICU LOS. Future studies into SGLT2i management perioperatively are important.

Real world SARS-COV-2 vaccine effectiveness in a Miami academic institution.

BACKGROUND: To assess the effectiveness of messenger RNA vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) in preventing emergency department (ED) presentations for acute respiratory illness. BASIC PROCEDURES: We conducted a retrospective study assessing adult presentations (age ≥ 18) to the University of Miami Hospital's ED from January 1st through August 25th, 2021, with a SARS-COV-2 PCR test and acute respiratory infection symptoms. Vaccine effectiveness was calculated using a test-negative design. Both univariable and multivariable (adjusted for age, gender, race, insurance status, imputed body mass index [BMI], vaccine type, week of presentation) regression analyses were conducted for the full cohort and subgroups. MAIN FINDINGS: The cohort consisted of 13,203 ED presentations-3134 (23.7%) fully vaccinated and SARS-COV-2 negative, 108 (0.8%) fully vaccinated and SARS-COV-2 positive, 8817 (66.8%) unvaccinated and SARS-COV-2 negative, and 1144 (8.7%) unvaccinated and SARS-COV-2 positive. Unadjusted vaccination effectiveness was 73.4% (95% confidence interval: 67.5%,78.3%) and, after adjustment, 73.8% (66.2%,79.7%). The Moderna vaccine's effectiveness was numerically higher (unadjusted: 78.2% [68.8%, 84.7%]; adjusted: 78.0% [68.1%, 84.9%]) than the Pfizer vaccine's (unadjusted: 70.8% [62.9%, 76.9%]; adjusted: 73.9% [66.3%,79.8%]). We found a significant difference in adjusted vaccine effectiveness across categories was BMI (p < 0.001)-BMI <25: 66.3% (45.3%,79.2%); BMI 25-29: 71.3% (56.1%, 81.2%); BMI 30-34: 84.5% (71.7%, 91.5%); and BMI ≥35: 72.7% (50.5%, 84.9%). PRINCIPAL CONCLUSIONS: We demonstrated excellent real-world effectiveness of mRNA vaccines in preventing ED presentation for SARS-COV-2 in a diverse U.S. COHORT: Notably, vaccine effectiveness improved with increasing BMI (until class 2 obesity).

Bloodstream Infection Risk, Incidence, and Deaths for Hospitalized Patients during Coronavirus Disease Pandemic.

Hospital-acquired infections are emerging major concurrent conditions during the coronavirus disease (COVID-19) pandemic. We conducted a retrospective review of hospitalizations during March‒October 2020 of adults tested by reverse transcription PCR for severe acute respiratory syndrome coronavirus 2. We evaluated associations of COVID-19 diagnosis with risk for laboratory-confirmed bloodstream infections (LCBIs, primary outcome), time to LCBI, and risk for death by using logistic and competing risks regression with adjustment for relevant covariates. A total of 10,848 patients were included in the analysis: 918 (8.5%) were given a diagnosis of COVID-19, and 232 (2.1%) had LCBIs during their hospitalization. Of these patients, 58 (25%) were classified as having central line‒associated bloodstream infections. After adjusting for covariates, COVID-19‒positive status was associated with higher risk for LCBI and death. Reinforcement of infection control practices should be implemented in COVID-19 wards, and review of superiority and inferiority ranking methods by National Healthcare Safety Network criteria might be needed.

Candida auris Invasive Infections during a COVID-19 Case Surge.

Clinical cases of C. auris noted during a COVID-19 surge led to an epidemiological, clinical, and genomic investigation. Evaluation identified a close genetic relationship but inconclusive epidemiologic link between all cases. Prolonged hospitalization due to critical illness from COVID-19 and use of antimicrobials may have contributed to clinical infections.

Feasibility and acceptability of a self-managed exercise to rhythmic music intervention for ICU survivors.

BACKGROUND: Post-ICU rehabilitation is a challenging clinical issue for patients discharged from an Intensive Care Unit ("ICU survivors"). Our exercise to rhythmic music intervention was designed to allow ICU survivors to self-manage their exercise by following a personalized, recorded exercise playlist. AIM: Our study reports the feasibility and acceptability of an innovative music intervention among ICU survivors enrolled in a randomized controlled pilot study. METHODS: ICU survivors, admitted in ICU for at least 5 days and cognitively intact, were randomly assigned to an exercise to rhythmic music group (n = 10) or an active control group (n = 10). Participants in the music group were taught to self-manage exercise by listening to a recorded playlist of instructions and music-facilitated movements tailored to their musical preference and exercise ability. Participants in the control group were provided a brochure with exercise instructions. After 5 days or at hospital discharge, participants completed an 8-item acceptability questionnaire and were interviewed. Content analysis was conducted. RESULTS: 18 Participants were included for final analysis. Participants were 61.8 ± 14.7 years old, predominantly male (66.7%), and Caucasian (55.6%). Results demonstrated feasibility, as the study team was able to meet the enrollment goal of 5-6 participants per month. Three themes related to general, physical, and psychosocial benefits were identified. Based on positive feedback, the exercise to rhythmic music intervention was deemed acceptable. CONCLUSION: The exercise to rhythmic music intervention was feasible and acceptable, suggesting that clinical trials with larger sample sizes should investigate the effects of the intervention on outcomes among ICU survivors.

Prevention of Stroke in Atrial Fibrillation After Coronary Stenting.

Background and Purpose- The optimal antithrombotic strategy to balance thromboembolic and bleeding events, especially acute stroke, for patients with atrial fibrillation following coronary stenting remains a matter of debate. We conducted a network meta-analysis to identify the antithrombotic regimen associated with the lowest rate of bleeding and thromboembolic events in atrial fibrillation after coronary stenting. Methods- PubMed, Scopus, and Cochrane Central were searched for randomized controlled trials and observational studies of patients with atrial fibrillation after coronary stenting. The outcomes of interest were stroke, myocardial infarction, major adverse cardiac events, mortality, and major bleeding. A network meta-analysis was performed comparing the available antithrombotic regimens in the literature. Results- Three randomized and 15 observational studies were included, with a total of 23 478 participants. Median follow-up was 2 years. Network meta-analysis demonstrated that vitamin K antagonist plus single antiplatelet therapy or direct-acting oral anticoagulant plus single antiplatelet therapy were the most effective regimens in preventing stroke. Direct-acting oral anticoagulant regimens were associated with lower major bleeding rates than vitamin K antagonist regimens. Regimens with dual antiplatelet therapy were associated with lower rates of myocardial infarction. Vitamin K antagonist plus dual antiplatelet therapy was associated with a lower mortality and low-dose direct-acting oral anticoagulants with decreased major cardiovascular adverse events. Conclusions- Direct-acting oral anticoagulant regimens were associated with less major bleeding and major cardiovascular adverse events, but vitamin K antagonists were associated with decreased mortality and stroke. These results suggest that the decision of antithrombotic therapy in patients with atrial fibrillation after percutaneous coronary intervention needs to be individualized.

The Impact of Adding a 2-Way Video Monitoring System on Falls and Costs for High-Risk Inpatients.

OBJECTIVES: We aimed to investigate the value of adding a video monitoring (VM) system with falls and costs for patients at high risk. METHODS: We conducted a retrospective, historically controlled study of adults (≥18 y old) at high risk of fall admitted at the University of Miami Hospital and Clinics from January 1 to November 30, 2020 (pre-VM) and January 1 to November 30, 2021 (post-VM); in-person sitters were available in both periods. Fall risk assessment was conducted on admission and at every nursing shift; we defined patients as high risk if their Morse Fall Scale was ≥60. We conducted a multivariable logistic regression model to evaluate the association of period (pre- versus post-VM) with falls and performed a cost analysis. RESULTS: Our primary cohort consisted of 9,034 patients at high risk of falls, 4,207 (46.6%) in the pre-VM and 4,827 (53.4%) in the post-VM period. Fall rates were higher in the pre- than the post-VM periods (3.5% versus 2.7%, P = 0.043). After adjustment, being admitted during the post-VM period was associated with a lower odds of fall (odds ratio [95% confidence interval], 0.49 [0.37-0.64], P < 0.001). The median adjusted hospital cost (in 2020 dollars) was $1,969 more for patients who fell than for patients who did not (interquartile range, $880-$2,273). Considering start-up and ongoing costs, we estimate VM implementation to partly replace in-person monitoring has potential annual cost savings of >$800,000 for a hospital similar to ours. CONCLUSIONS: Video monitoring to augment in-person sitters is an effective fall prevention initiative for patients at high risk of falls, which is likely also cost-effective.

Changes in Telomere Length and Indicators of Oxidative Stress in Critically Ill Mechanically Ventilated Adults - A Pilot Study.

BACKGROUND: Telomeres are structures at the end of chromosomes that shorten with each cell division. The purpose of this pilot project is to report changes in telomere length (T/S ratio), indicators of oxidative stress (serum protein carbonyl, vitamin C, GSH:GSSG, and total antioxidant capacity) from Intensive Care Unit (ICU) admission to ICU discharge, and to explore their association with ICU-related morbidities among critically ill mechanically ventilated adults. METHODS: Blood was collected from mechanically ventilated patients (n = 25) at enrollment and within 48 hours of ICU discharge. Telomere length from peripheral blood mononuclear cells (PBMCs) was determined using RTqPCR. ELISAs were used to measure indicators of oxidative stress. Descriptive analysis, paired t-tests, and Pearson's correlations were performed. RESULTS: Mean age was 62.0 ± 12.3 years, 28.6% were male, and 76.2% were White with disease severity using APACHE III (74.6 ± 24.6) and SOFA (7.6 ± 3.2). Mean T/S ratios shortened (ICU: 0.712, post-ICU: 0.683, p < 0.001, n = 19) and serum protein carbonyl increased (ICU: 7437 nmol/mg ± 3328, post-ICU: 10,254 nmol/mg ± 3962, p < 0.005) as did the oxidative stress index (protein carbonyl/GSH:GSSG, ICU: 1049.972 ± 420.923, post-ICU: 1348.971 ± 417.175, p = 0.0104). T/S ratio was positively associated with APACHE III scores (ICU: r = 0.474, post-ICU: r = 0.628, p < 0.05). CONCLUSIONS: Pilot findings suggest that critical illness significantly correlates with telomere attrition, perhaps due to increased oxidative stress. Future larger and longitudinal studies investigating mechanisms of telomere attrition and associations with clinical outcomes are needed to identify potential modifiable factors for subsequent intervention to improve outcomes for critically ill patients.

Weight Loss Effects of Glucagon-Like Peptide-One Receptor Analog Treatment in a Severely Obese Patient During Hospital Admission.

Obesity is considered an independent risk factor for increased hospital length of stay and can be an obstacle to a safe discharge. Although typically prescribed in the outpatient setting, initiating glucagon-like peptide-one receptor agonists (GLP-1RAs) in the inpatient setting can be efficacious in reducing weight and increasing functional status. We report the use of GLP-1RA therapy with liraglutide and subsequent transition to subcutaneous semaglutide weekly in a 37-year-old female with severe obesity, weighing 694 lbs (314 kg) with a body mass index (BMI) of 108 kg/m2. Multiple medical and socioeconomic factors impaired the patient from being safely discharged and ultimately led to prolonged hospitalization. The patient received 31 consecutive weeks of GLP-1RA therapy in the inpatient setting along with a very low-calorie diet (800 kcal/day). Initiation and up-titration doses were completed using liraglutide for a total of five weeks. Subsequently, the patient was transitioned to receive weekly semaglutide and completed 26 weeks of therapy. At the end of week 31, the patient's weight decreased by 174 lbs (79 kg), or 25% of baseline weight, and BMI decreased from 108 to 81 kg/m2. GLP-1RAs offer a promising avenue for weight loss interventions in patients with severe obesity in addition to lifestyle modifications. The weight loss observed in our patient at the halfway point of the total treatment duration is a milestone in the pathway to gaining functional independence and meeting the criteria for future bariatric surgery. Semaglutide, a GLP-1RA, can be an effective intervention for severely obese patients with BMI greater than 100 kg/m2.

Association of language concordance and restraint use in adults receiving mechanical ventilation.

PURPOSE: Clinician-patient language concordance improves patient outcomes in non-intensive care unit (ICU) settings. We sought to assess the association of ICU nurse-patient language concordance with delirium-related outcomes. METHODS: We conducted a retrospective cohort study of adult English- or Spanish-speaking mechanically ventilated ICU patients admitted to ICUs at the University of Miami Hospital and Clinics (January 2021-September 2022). Our primary exposure was nurse-patient language concordance on each shift. We used mixed-effects multivariable regression to evaluate the association of language concordance with the primary outcome of restraint use, and secondary outcomes of agitation and identification of delirium, during each shift (with patient as a random effect). RESULTS: Our cohort included 4326 shifts (3380 [78.1%] with language concordance) from 548 patients and 157 nurses. Spanish language was preferred by 269 (49.1%) of patients. English-speaking patients tended to be younger (65 [53, 75] vs 73 [61, 83], p < 0.001) and of non-Hispanic ethnicity (55.5% vs 7.1%, p < 0.001). English-speakers had restraints ordered on fewer of their included shifts (0 [0, 3] vs 1 [0, 3], p = 0.005). After adjustment, the odds of restraint use on shifts with language concordance was significantly lower (odds ratio [OR, 95% confidence interval [CI]]: 0.50 [0.39-0.63], p < 0.001). Agitation (18.6% vs 25.2%; OR [95% CI]: 0.71 [0.55-0.92], p = 0.009) and delirium identification (34.5% vs 41.3%; OR [95% CI]: 0.54 [0.34-0.88], p = 0.014) were also less common. CONCLUSIONS: We identified a twofold reduction in the odds of restraint use among mechanically ventilated patients for language concordant nurse-patient dyads. Ensuring nurse-patient language concordance may improve ICU delirium, agitation, and restraint use.

Persistent colonization of Candida auris among inpatients rescreened as part of a weekly surveillance program.

We established a surveillance program to evaluate persistence of C. auris colonization among hospitalized patients. Overall, 17 patients (34%) had ≥1 negative result followed by a positive test, and 7 (41%) of these patients had ≥2 consecutive negative tests.

Operational impact of decreased turnaround times for Candida auris screening tests in a tertiary academic medical center.

Objective: Assess turnaround time (TAT) and cost-benefit of on-site C. auris screening and its impact on length of stay (LOS) and costs compared to reference laboratories. Design: Before-and-after retrospective cohort study. Setting: Large-tertiary medical center. Methods: We validated an on-site polymerase chain reaction-based testing platform for C. auris and retrospectively reviewed hospitalized adults who screened negative before and after platform implementation. We constructed multivariable models to assess the association of screening negative with hospital LOS/cost in the pre and postimplementation periods. We adjusted for confounders such as demographics and indwelling device use, and compared TATs for all samples tested. Results: The sensitivity and specificity of the testing platform were 100% and 98.11%, respectively, compared to send-out testing. The clinical cohort included 287 adults in the pre and 1,266 postimplementation period. The TAT was reduced by more than 2 days (3 (interquartile range (IQR): 2.0, 7.0) vs 0.42 (IQR: 0.24, 0.81), p < 0.001). Median LOS was significantly lower in the postimplementation period; however, this was no longer evident after adjustment. In relation to total cost, the time period had an effect of $6,965 (95% CI: -$481, $14,412); p = 0.067) on reducing the cost. The median adjusted total cost per patient was $7,045 (IQR: $3,805, $13,924) less in the post vs the preimplementation period. Conclusions: Our assessment did not find a statistically significant change in LOS, nevertheless, on-site testing was not cost-prohibitive for the institution. The value of on-site testing may be supported if an institutional C. auris reduction strategy emphasizes faster TATs.

Combined Use of RT-qPCR and NGS for Identification and Surveillance of SARS-CoV-2 Variants of Concern in Residual Clinical Laboratory Samples in Miami-Dade County, Florida.

Over the course of the COVID-19 pandemic, SARS-CoV-2 variants of concern (VOCs) with increased transmissibility and immune escape capabilities, such as Delta and Omicron, have triggered waves of new COVID-19 infections worldwide, and Omicron subvariants continue to represent a global health concern. Tracking the prevalence and dynamics of VOCs has clinical and epidemiological significance and is essential for modeling the progression and evolution of the COVID-19 pandemic. Next generation sequencing (NGS) is recognized as the gold standard for genomic characterization of SARS-CoV-2 variants, but it is labor and cost intensive and not amenable to rapid lineage identification. Here we describe a two-pronged approach for rapid, cost-effective surveillance of SARS-CoV-2 VOCs by combining reverse-transcriptase quantitative polymerase chain reaction (RT-qPCR) and periodic NGS with the ARTIC sequencing method. Variant surveillance by RT-qPCR included the commercially available TaqPath COVID-19 Combo Kit to track S-gene target failure (SGTF) associated with the spike protein deletion H69-V70, as well as two internally designed and validated RT-qPCR assays targeting two N-terminal-domain (NTD) spike gene deletions, NTD156-7 and NTD25-7. The NTD156-7 RT-qPCR assay facilitated tracking of the Delta variant, while the NTD25-7 RT-qPCR assay was used for tracking Omicron variants, including the BA.2, BA.4, and BA.5 lineages. In silico validation of the NTD156-7 and NTD25-7 primers and probes compared with publicly available SARS-CoV-2 genome databases showed low variability in regions corresponding to oligonucleotide binding sites. Similarly, in vitro validation with NGS-confirmed samples showed excellent correlation. RT-qPCR assays allow for near-real-time monitoring of circulating and emerging variants allowing for ongoing surveillance of variant dynamics in a local population. By performing periodic sequencing of variant surveillance by RT-qPCR methods, we were able to provide ongoing validation of the results obtained by RT-qPCR screening. Rapid SARS-CoV-2 variant identification and surveillance by this combined approach served to inform clinical decisions in a timely manner and permitted better utilization of sequencing resources.

The clinical effectiveness of REGEN-COV in SARS-CoV-2 infection with Omicron versus Delta variants.

BACKGROUND: In vitro studies suggesting that REGEN-COV (casirivimab plus imdevimab monoclonal antibodies) had poor efficacy against Omicron-variant SARS-CoV-2 infection led to amendment of REGEN-COV's Emergency Use Authorization to recommend use only in regions without high Omicron prevalence. REGEN-COV's relative clinical effectiveness for Omicron is unknown. METHODS AND FINDINGS: We conducted a retrospective cohort study of non-hospitalized adults who tested positive for SARS-CoV-2 by polymerase chain reaction at the University of Miami Health System from July 19 -November 21, 2021 (Delta period) and December 6, 2021 -January 7, 2022 (Omicron period). Subjects were stratified be REGEN-COV receipt within 72h of test positivity and by time period of infection. We constructed multivariable logistic regression models to assess the differential association of REGEN-COV receipt with hospitalization within 30 days (primary outcome) and ED presentation; all models included three exposure terms (REGEN-COV receipt, Omicron vs Delta period, interaction of REGEN-COV with time period) and potential confounders (vaccination status, vaccine boosting, cancer diagnosis). Our cohort consisted of 2,083 adults in the Delta period (213 [10.2%] received REGEN-COV) and 4,201 in the Omicron period (156 [3.7%] received REGEN-COV). Hospitalization was less common during the Omicron period than during Delta (0.9% vs 1.7%, p = 0.78) and more common for patients receiving REGEN-COV than not (5.7% vs 0.9%, p<0.001). After adjustment, we found no differential association of REGEN-COV use during Omicron vs Delta with hospitalization within 30d (adjusted odds ratio [95% confidence interval] for the interaction term: 2.31 [0.76-6.92], p = 0.13). Similarly, we found no differential association for hospitalization within 15d (2.45 [0.63-9.59], p = 0.20) or emergency department presentation within 30d (1.43 [0.57-3.51], p = 0.40) or within 15d (1.79 [0.65-4.82], p = 0.30). CONCLUSIONS: Within the limitations of this study's power to detect a difference, we identified no differential effectiveness of REGEN-COV in the context of Omicron vs Delta SARS-CoV-2 infection.

Association of care by a non-medical intensive care unit provider team with outcomes of medically critically ill patients.

OBJECTIVE: To determine the association of boarding of critically ill medical patients on non-medical intensive care unit (ICU) provider teams with outcomes. DESIGN: A retrospective cohort study. SETTING: ICUs in a tertiary academic medical center. PATIENTS: Patients with medical critical illness. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: We compared outcomes for critically ill medical patients admitted to a non-medical specialty ICU team (April 1 - August 30, 2020) with those admitted to the medical ICU team (January 1, 2018 - March 31, 2020). The primary outcome was hospital mortality; secondary outcomes were hospital length of stay (LOS) and hospital disposition for survivors. Our cohort consisted of 1241 patients admitted to the medical ICU team and 230 admitted to non-medical ICU teams. Unadjusted hospital mortality (medical ICU, 38.8% vs non-medical ICU, 42.2%, p = 0.33) and hospital LOS (7.4 vs 7.4 days, p = 0.96) were similar between teams. Among survivors, more non-medical ICU team patients were discharged home (72.6% vs 82.0%, p = 0.024). After multivariable adjustment, we found no difference in mortality, LOS, or home discharge between teams. However, among hospital survivors, admission to a non-medical ICU team was associated with a longer LOS (regression coefficient [95% CI] for log-transformed hospital LOS: 0.23 [0.05,0.40], p = 0.022). Certain subgroups-patients aged 50-64 years (odds-ratio [95% CI]: 4.22 [1.84,9.65], p = 0.001), with ≤10 comorbidities (0-5: 2.78 (1.11,6.95], p = 0.029; 6-10: 6.61 [1.38,31.71], p = 0.018), without acute respiratory failure (1.97 [1.20,3.23], p = 0.008)-had higher mortality when admitted to non-medical ICU teams. CONCLUSIONS: We found no association between admission to non-medical ICU team and mortality for medically critically ill patients. However, survivors experienced longer hospital LOS when admitted to non-medical ICU teams. Middle-aged patients, those with low comorbidity burden, and those without respiratory failure had higher mortality when admitted to non-medical ICU teams.