Changes in HIV Prevention & Sexual Experiences During the COVID-19 Pandemic: A mixed-methods study.

BACKGROUND: STI and HIV services and infection rates were impacted during the COVID-19 pandemic, due to changes in access to healthcare as well as individual behavior. Understanding how individuals made decisions around prevention and sexual activities during different phases of the pandemic is useful to addressing the rising rates of STIs and HIV. SETTING: Federally-qualified health center focused on sexual and gender minority health, Chicago IL, 2021. METHODS: Patients with a history of PrEP use who were contacted by the PrEP retention team as part of standard care were invited to complete an online survey. A subset of survey participants were then contacted to complete one-on-one interviews. Participants were asked about two distinct periods: November 2020 to January 2021 and February to June 2021. RESULTS: From the 356 survey participants (mostly young, insured, and experienced with PrEP), more than half maintained their number of sex partners during the early pandemic and the majority also maintained PrEP use; during the later pandemic, the majority reported more or the same number of sex partners and almost all maintained PrEP use. From interviews, we identified diverse and changing experiences regarding sexual practices throughout the pandemic; while many participants changed PrEP use in accordance with sexual practices, many others maintained PrEP use as a habit. COVID-19 prevention was also a factor in sexual activities, particularly pre-vaccination. CONCLUSION: Many PrEP users try to align their HIV prevention with their sexual exposures and establish PrEP as a long-term habit. Removing financial and access barriers is important to improve PrEP use and STI testing.

Improving Patient Portal Enrollment in the Pediatric Emergency Department: A Quality Improvement Project

Purpose/Objectives: Access to a patient portal has been shown to improve patient satisfaction and customer retention, and increases telehealth options for families, which has become essential during COVID-19. Unfortunately, portal enrollment after emergency department (ED) visit has historically been very low at our institution, with less than one percent of patients enrolling within ten days of their visit. Our primary objective was to increase the percentage of eligible emergency department patients who enroll in the patient portal within 10 days of their ED visit from 0.3% to 5% by May 2021 and sustain improvements for 6 months. Design/Methods: A multidisciplinary team of ED providers and ancillary staff developed a working group to create a key driver diagram and plan interventions across the department. Interventions focused on improving portal invite dissemination, improving visibility and access on our portal website, and enhancing access for families to receive an invite after departure. Data were collected on all eligible participants presenting to two urban freestanding pediatric emergency departments. Given portal age and security constraints, initial eligible patients were those aged 0-12 or 18 and older who were not previously enrolled (from baseline until March 2021). Secondary to the CURES Act and changes in the EHR (electronic health record), eligible patients from April 2021 onward included all patients not previously enrolled in all age groups. Sequential PDSA (Plan-Do-Study-Act) cycles were completed with review of monthly enrollment trends and implementation of new interventions to improve portal enrollment after discharge, including web-based changes, registration service changes, and education of ED faculty and staff on portal enrollment. We followed the percentage of invites sent and percent uptake as process measures. Results: Prior to project initiation, baseline portal enrollment for eligible patients within 10 days of ED visit was 0.3%. A p-chart with monthly data shows significant and sustained improvement in patient portal enrollment with special cause variation and baseline shift to six percent at our main facility and three percent at our secondary site. Similar trends were observed at both ED sites. Website updates and educational interventions demonstrated the most significant changes. With CURES act implementation and changes to the institutions' EHR invitation process, expected drops in enrollment were seen. Conclusion/Discussion: Significant improvements in patient portal enrollment were made during this quality improvement project and appear to be sustained at this time. Further interventions to improve enrollment focusing on streamlined portal access between clinic and ED sites, as well as a centralized portal help desk, are planned to sustain these improvements. Percentage of Eligible Patients Enrolled in the Portal by 10 Days After ED Visit (Main Campus) P chart showing percentage of eligible patients who enrolled in the patient portal within 10 days of a visit to our main ED campus. Eight points above the center line, starting in October 2020, led to a baseline shift from initial 0.3 percent to six percent following interventions. Percentage of Eligible Patients Enrolled in the Portal by 10 Days After ED Visit (SA Campus) P chart showing percentage of eligible patients who enrolled in the patient portal within 10 days of a visit to our secondary ED campus (abbreviated SA for location). Eight points above the center line, starting in October 2020, led to a baseline shift from initial 0.1 percent to 3.4 percent following interventions.

Sentinel Case of COVID-19 at Fort Stewart, GA in a National Guard Soldier Participating in Annual Training: A Case Report

For healthcare providers, specifically military and federal public health personnel, prompt and accurate diagnosis and isolation of SARS-CoV-2 novel coronavirus patients provide a two-fold benefit: (1) directing appropriate treatment to the infected patient as early as possible in the progression of the disease to increase survival rates and minimize the devastating sequelae following recovery and remission of symptoms;(2) provide critical information requirements that enable commanders and public health officials to best synchronize policy, regulations, and troop movement restrictions while best allocating scarce resources in the delicate balance of risk mitigation versus mission readiness. Simple personal protective measures and robust testing and quarantine procedures, instituted and enforced aggressively by senior leaders, physicians, and healthcare professionals at all levels are an essential aspect of the battle against the COVID-19 pandemic that will determine the success or failure of the overall effort. As consideration, the authors respectfully submit this vignette of the first confirmed positive COVID-19 case presenting to the Emergency Department at Winn Army Community Hospital, Fort Stewart, Georgia.

COVID-19 in Patients With Cancer

Study Objective: The COVID-19 pandemic caused by the severe acute respiratory coronavirus 2 (SARS-CoV-2) has significantly affected the provision of routine and acute medical care. The aim of this report is to characterize patients with cancer presenting to EDs in the United States and COVID-19 mortality risk according to tumor subtype. Methods: The RECOVER registry represents a collaboration between 45 EDs spanning 27 states. This retrospective registry enrolled patients from each study site who received molecular diagnostic testing as part of ED care due to clinical suspicion for COVID-19 disease. Clinical characteristics pertaining to a patient’s cancer status were obtained from medical record review, specifically cancer type, active versus remission status, metastatic versus isolated tumor, and hematologic versus solid tumor status. Cancer type was further classified as solid/hematologic tumor localized or metastatic based on documented diagnoses and/or past medical history. Results: There are a total of 2865 patients who have a reported history of cancer, 1899 (66.3%) were negative for COVID-19 and 33.7% were positive on COVID-19 testing. There are higher percentages of minority-identifying patients in the COVID-19 positive cohort as compared to the negative cohort, namely Black or African American (33.9% vs 13.5%, respectively, p<0.001), and unknown/other (20.5% vs. 7.1%, p<0.001). Breast cancer was the most common solid tumor presenting in this cohort, with 19.6% of the COVID-positive cohort compared to 9.6% of the COVID-negative cohort (p=0.099). The next most common cancers in the cohort were colorectal (7.5%) and prostate (6.9%), however there were no statistical differences between the cohorts. The mortality rate for COVID-19 positive patients was 24.2% versus 9.9% for the COVID-19 negative rate (p<0.001, OR 1.96). Patients with breast cancer had a much higher mortality rate when associated with a COVID-19 positive test (26.4% versus 10.2%, p<0.001, OR 3.27). Similarly, colorectal cancer, prostate cancer, and leukemias experienced higher mortality rates for COVID-19 positive patients, 31.4% versus 13.2%, 31% versus 12.4%, and 30.8% versus 16.4% (all p<001). For patients with a documented history of cancer in remission, they also experienced higher mortality rates when associated with a positive COVID-19 test, namely 21.3% versus 7.2%. Conclusion: This study represents one of the largest COVID-19 cancer-related studies with 966 patients with a history of active cancer and SARS-CoV-2 infection. Patients with cancer present to the ED with diverse symptoms, treatment regimens, and having a diagnosis of COVID-19 is associated with higher mortality rates. Because of the high mortality rates observed for several of the cancer types in this study, initial evaluation of patients in the ED, subsequent ED therapies, and close communication with treating oncologists is of the utmost importance. [Formula presented]

Health Insurance and Duration of Symptoms Prior to Emergency Department Visit: An Analysis of 19,850 Patients With Suspected COVID-19

Study Objectives: The COVID-19 pandemic has emphasized disparities in health outcomes across social and economic strata. The mechanisms of this relationship are poorly understood, but the length of time patients exhibit symptoms prior to getting tested for COVID-19 increases the opportunity for community transmission. We hypothesized that there is a relationship between insurance coverage and the duration of COVID-19 symptoms prior to seeking care at the emergency department (ED). Methods: A national, multi-institution (n=45 sites) registry collected information on ED visits in which patients were tested for suspected COVID-19. Demographics and clinical characteristics were summarized for the total cohort. Insurance was categorized into private (private or commercial), public (Medicare, Medicaid, or dual-eligible), worker’s compensation or unknown, or no health insurance. Negative binomial regression was used to analyze both the unadjusted and adjusted relationship between insurance and the time from symptom onset to ED presentation. Adjustments included age, sex, race, ethnicity, medical history, smoking status, drug use, and number of COVID symptoms. Results: Baseline demographic and clinical characteristics of included patients (n=19,850) are displayed in Table 1. The average time from symptom onset to ED presentation among patients with suspected COVID-19 was 5.4 days. In unadjusted analysis, patients with private insurance had significantly longer time of symptom onset prior to ED presentation than patients with public insurance (5.6 vs. 5.3 days, p=0.007). After multivariate adjustment, increased duration of symptoms prior to ED presentation was significantly associated with private insurance [rate ratio (RR) 1.07, 95% confidence interval (CI): 1.03 – 1.10] and no health insurance (RR 1.06, 95% CI: 1.07 – 1.13) compared to public insurance (Figure 1). Patients residing in states with Medicaid expansion were not independently associated with the increased time to ED presentation (RR 1.03, 95% CI: 1.00 – 1.07). Conclusion: Patients with private insurance or no insurance waited significantly longer to present to the ED. The extended duration of symptoms prior to presentation increases the opportunities for community transmission. The results from this study can be used by health systems to target the patients at increased risk for delayed ED presentation. [Formula presented]

Therapeutic outcomes following tocilizumab administration in patients with severe COVID-19

INTRODUCTION: Immunomodulation has been suggested as a treatment for COVID-19 to manage the hyperinflammatory state caused by cytokine release. Tocilizumab (TCZ) is an interleukin-6 (IL-6) monoclonal antibody approved for T-cell therapy induced cytokine release syndrome (CRS) and may provide benefit in COVID-19 patients with CRS. This study was conducted to assess clinical outcomes in patients with severe COVID-19 treated with TCZ. METHODS: Retrospective, single center, cohort study of adults with severe COVID-19 admitted to the intensive care unit who received TCZ between March 2020 to April 2020. All doses of TCZ were 400 mg given intravenously. A control group of severe COVID-19 patients who did not receive TCZ was randomly selected for comparison based upon similar baseline demographics (APACHE IV, SOFA score, age, gender, mechanical ventilation, multi-system organ failure (MSOF), and prone therapy). COVID-19 treatments received, temperature, inflammatory markers, mortality, diagnosis of superimposed infection and length of stay (LOS) was also collected. RESULTS: 25 patients who received TCZ and 17 patients who did not receive TCZ were included in the study. Baseline demographics were not significantly different between the TCZ vs. control group (APACHE IV = 53 vs. 55;SOFA score = 6.7 vs. 7.2). All patients were mechanically ventilated and 88% of patients in each group were diagnosed with MSOF. Maximum temperature and inflammatory markers were not significantly different (median IL-6 = 157.8 pg/mL vs. 131.5 pg/mL). There was no significant difference between the number of patients who received hydroxychloroquine, azithromycin, steroids, remdesivir, or convalescent plasma. 16 patients (64%) in the TCZ group received one dose and 9 (36%) received two doses. The mortality rate was not significantly different (8/25, 32% vs. 5/17, 29%;p = 0.86). The incidence of superimposed infection following TCZ administration was significantly higher compared to the incidence of superimposed infection at any time during admission for the control group (18/25, 72% vs. 7/17, 41%;p = 0.045). Mean LOS was 27 days vs. 19 days. CONCLUSIONS: There was no significant difference in mortality in COVID-19 patients who received TCZ. Our study suggests that patients who receive TCZ are at a significantly higher risk of infection.

SARS CoV-2-associated multisystem inflammatory syndrome of children (MIS-C) in the Washington DC metropolitan region

Background: Background: Multi-system Inflammatory Syndrome of Children (MIS-C) has recently emerged internationally as a serious inflammatory complication of SARS-CoV-2 infection with significant morbidity for the pediatric population. Methods: This observational retrospective cohort study includes 33 children meeting CDC criteria for MIS-C treated between March 15 and June 17, 2020 at Children's National Hospital in Washington DC. Clinical and demographic data were extracted from medical records and are summarized. Results: Of 33 hospitalized MIS-C patients, 42% were critically ill, and 58% were non-critically ill. The median age was 8.9 years (0.7-18.7 years). More males (58 %) than females (43 %) were represented in the MIS-C cohort. The majority (75%) of children had no underlying medical condition. Criteria for incomplete or complete Kawasaki Disease (KD) were present in 39% of patients, while an additional 9% had some features of KD. However the remaining 52% of MIS-C patients presented with other sub-phenotypes including prominent severe abdominal pain and/or nonspecific multiorgan dysfunction. 30% presented with shock requiring volume and/or inotropic support. SARS-CoV-2 antibodies were present in 61% of patients. Virus was detectable by PCR in 36% of patients. At the time of initial evaluation, 39% (13/33) of children had identified cardiac abnormalities including myocardial dysfunction (5/33;15%), coronary ectasia (4/33;12%), coronary aneurysm (3/33;9%), or pericardial effusion 5/33;15%) either alone or in combination. Cytokine profiling identified elevation of several cytokines in this cohort, including IL-6. Treatment has included intravenous immunoglobulin, aspirin, anakinra and other immunomodulatory therapies, with overall rapid response to therapy. No deaths have occurred. Conclusion: The emergence of MIS-C late in the surge of SARS-CoV-2 circulation in the Washington DC metropolitan region has added to the already significant burden of hospitalized and critically ill children in our region. A significant percentage of these children present with cardiac dysfunction and abnormalities, whether or not with KD features at presentation. Detailed characterization of immune responses and long term outcome of these patients is a priority.