Heart failure training course for home health aides in New York city: A mixed methods pilot study

Introduction: Although home health aides (HHAs) often care for adults with heart failure (HF), studies have found that the majority have not received HF training and lack confidence with HF caregiving. To address this, we tested the feasibility, acceptability, and effectiveness of a virtual HF training course for HHAs. Methods: We partnered with the Education Fund of the 1199SEIU United Health Care Workers East, the largest healthcare union in the US, which provides training to 55,000 HHAs in NYC. HHAs typically receive in-person training, but due to COVID-19, we conducted this course virtually. The 2- hour course, taught in English and Spanish, utilized case-based learning and motivational interviewing to engage HHAs in interactive discussions on HF signs, symptoms, and HF self-care. HHAs with access to Zoom (via smartphone, computer, or tablet) were eligible. We conducted pre/post surveys and semi-structured interviews. Measures included: a) feasibility (attendance, retention), b) acceptability (modality, technological ease, satisfaction);and c) effectiveness (change in knowledge [Dutch Heart Failure Knowledge Scale, range 0-15] and caregiving self-efficacy [HF Caregiver Self-efficacy Scale, range 0-100]). Results: 48 HHAs employed by 15 distinct home care agencies enrolled and completed the course;course size ranged from 4-9 participants. The majority were middle-age women (60% Hispanic, 10% non-Hispanic Black). To participate, 59% used a smartphone, 32% a computer, and 10% a tablet. Compared to prior in-person courses, 83% participants reported that the course ran more smoothly and was more convenient;only 7% reported technical problems. Participants and course instructors reported high levels of satisfaction and engagement. Post-course data showed significant and clinically meaningful improvements in HF knowledge (11.21 [1.90] v. 12.21 [1.85];p = 0.0000) and HF caregiving self-efficacy (75.21 [16.57] v. 82.29 [16.49];p = 0.0017). Conclusions: A virtual HF training course was feasible and acceptable among HHAs and improved their HF knowledge and caregiving confidence. Efforts to scale and disseminate the course may be warranted. Future studies are needed to test the effect of the course among HHAs and their patients.

CONVERSION RATE FOR COVID19 IN NEW YORK CITY: IMPACT OF SOCIAL DISTANCING AND UNIVERSAL MASKING

We reported the results of our multicenter cohort study in all patients who presented for endoscopy between March 1 and May 17 and were evaluated before their endoscopy for SARS-CoV2 and were followed after their endoscopy for COVID-19 status. This cohort enabled us to calculate the conversion rate from COVID-19 negative to positive during the study period and evaluate the change in conversion rate with the implementation of social distancing and masking at the population level in New York City. Data were retrieved from electronic medical records systems of six tertiary care centers in New York City. We identified all adult patients who had endoscopy between March 1, and May 17, 2020. Conversion was defined as having a negative COVID-19 status before endoscopy and a positive status afterwards. Participants COVID-19 status was defined based on SARS-CoV2 PCR test or a combination of symptoms (Fever plus at least one of: dyspnea, cough, dysgeusia, or anosmia). Patients were evaluated before endoscopy and then by phone or telehealth visit afterwards. Spline regression was used to evaluate the conversion rate before and after adoption of social distancing (March 20, 2020) and mandatory masks (April 15, 2020) in New York City. Of the 1467 patients presenting for endoscopy during the study period, we had follow-up data on 1222 patients (51% outpatient and 49% inpatient endoscopies). Overall, 78 participants (6.38 %) converted after endoscopy (74 with a positive PCR, and 4 with symptoms as defined above), at a median of 23 days after endoscopy (IQR 11 to 42 days). Patients had a mean age of 62±15 years, and were 62% male (n=48). Multivariable analysis demonstrated that date of endoscopy, institution, and presence of cardiovascular disease were the independent predictors of conversion after endoscopy, with cardiovascular disease associated with a more than 2 fold increase in the risk of conversion (OR=2.1, 95%CI 1.2-3.6, p=0.009). The range of conversion from the six institutions varied widely (1 to 11%, p=0.035). Overall, participants whose endoscopies were performed later during the study period had a lower risk of conversion (OR for one week=0.87, 95%CI 0.80-0.94, p=0.001). Before social distancing, conversion rate was 8.4% on average and was increasing by 2.3% per week (p<0.001). After social distancing, the conversion rate was 6.7% on average, and started to decrease by 4.2% per week (p<0.001). After mandatory masks, the conversion rate was 2.2% on average but has started to increase slowly by 0.9% per week (p<0.001;see figure 1). These findings do support decrease in conversion rate amongst New Yorkers who presented for endoscopy with the implementation of social distancing and mandatory masking. We believe the slow but significant increase in conversion rates by the end of May reflects the relative loosening in social distancing in New York City.(Figure Presented)

Association between overcrowded households, multigenerational households, and COVID-19: a cohort study.

OBJECTIVES: The role of overcrowded and multigenerational households as a risk factor for COVID-19 remains unmeasured. The objective of this study is to examine and quantify the association between overcrowded and multigenerational households and COVID-19 in New York City (NYC). STUDY DESIGN: Cohort study. METHODS: We conducted a Bayesian ecological time series analysis at the ZIP Code Tabulation Area (ZCTA) level in NYC to assess whether ZCTAs with higher proportions of overcrowded (defined as the proportion of the estimated number of housing units with more than one occupant per room) and multigenerational households (defined as the estimated percentage of residences occupied by a grandparent and a grandchild less than 18 years of age) were independently associated with higher suspected COVID-19 case rates (from NYC Department of Health Syndromic Surveillance data for March 1 to 30, 2020). Our main measure was an adjusted incidence rate ratio (IRR) of suspected COVID-19 cases per 10,000 population. Our final model controlled for ZCTA-level sociodemographic factors (median income, poverty status, White race, essential workers), the prevalence of clinical conditions related to COVID-19 severity (obesity, hypertension, coronary heart disease, diabetes, asthma, smoking status, and chronic obstructive pulmonary disease), and spatial clustering. RESULTS: 39,923 suspected COVID-19 cases were presented to emergency departments across 173 ZCTAs in NYC. Adjusted COVID-19 case rates increased by 67% (IRR 1.67, 95% CI = 1.12, 2.52) in ZCTAs in quartile four (versus one) for percent overcrowdedness and increased by 77% (IRR 1.77, 95% CI = 1.11, 2.79) in quartile four (versus one) for percent living in multigenerational housing. Interaction between both exposures was not significant (ßinteraction = 0.99, 95% CI: 0.99-1.00). CONCLUSIONS: Overcrowdedness and multigenerational housing are independent risk factors for suspected COVID-19. In the early phase of the surge in COVID cases, social distancing measures that increase house-bound populations may inadvertently but temporarily increase SARS-CoV-2 transmission risk and COVID-19 disease in these populations.

Assessing mortality difference across COVID-19 intubation strategies

Rationale: The optimal timing of invasive mechanical ventilation (IMV) among patients with COVID-19 related acute respiratory failure (ARF) is unknown. Use of high flow nasal cannula (HFNC) support could potentially avoid the need for IMV and related risks. However, patients failing HFNC may be at increased risk for peri-intubation complications such as cardiac arrest. At NewYork-Presbyterian Weill Cornell Medical Center (NYP-WCMC) and Lower Manhattan Hospital (LMH), an early IMV strategy prior to March 26th 2020. We subsequently switched to a prolonged observation strategy, supporting patients with non-invasive devices including HFNC. In this study, we compared in-hospital mortality in patients with ARF managed with early IMV strategy versus a prolonged observation strategy. Methods: This is a retrospective cohort study using the Weill Cornell COVID-19 Registry, which included 1869 patients admitted with a COVID-19 positive PCR test up until May 15, 2020. Patients at risk for intubation due to ARF, defined by requiring > 6 liters/min nasal cannula, were included. Patients who met ARF criteria prior to March 26, 2020 were in the early IMV strategy group, and those who met criteria on or after March 26, 2020 were in the prolonged observation strategy group. In-hospital mortality with intubation strategy as the main exposure was modelled with cox proportional hazards regression. Confounders included age, sex, BMI, comorbidities, severity of illness (SOFA) and hospital strain (difference between daily admissions and discharges). Both SOFA and hospital strain were calculated for each patient on the day that they developed ARF for modelling purposes. Results: We identified 774 patients at risk for intubation due to ARF (table), 141 were in the early IMV group and 633 were in the prolonged observation strategy group. Death occurred in 33.3% of patients in the early IMV group compared to 34.8% in the prolonged observation group. Patients in the early IMV group had a longer length of stay among survivors (27.2 ± 26.1 days vs 21.6 ± 22.8 days, p = .0213). Age-adjusted hazard ratio for death comparing early IMV versus prolonged observation was 1.35 (95% CI 0.86-2.12, which decreases to 0.87 (95% CI 0.52-1.45) after adjusting for confounders. Conclusion: In this retrospective observational study with a modest sized sample, early IMV strategy was not associated with excess mortality compared to prolonged observation. In resource constrained settings, prolonged observation with HFNC support is a reasonable hospital-level strategy in patients with ARF.

ECHOCARDIOGRAPHIC ABNORMALITIES ARE COMMON AMONG PATIENTS WITH COVID-19 INFECTION AND INDEPENDENTLY CONFER INCREASED RISK OF IN-HOSPITAL MORTALITY

Background Biomarker-evidenced myocardial injury is common among patients with COVID-19 infection and confers an increased risk of mortality. Prevalence and incremental prognostic impact of myocardial dysfunction is unknown. Methods Consecutive COVID-19 patients undergoing clinical echocardiography during their index hospitalization at three New York City hospitals were studied. Images were analyzed by a central core lab blinded to all clinical data. LV dysfunction was defined as LVEF < 55% and RV dysfunction as TAPSE <1.6 cm or S’<10 mm/s. Results 733 patients (64 ± 15 years, 61% men) were studied. Myocardial injury (elevated troponin) occurred in 21% of patients, among whom either LV or RV myocardial dysfunction occurred in 72% (LV: 54%, RV:24%). Myocardial dysfunction was more common among patients with myocardial injury vs. without (LV: 54 vs. 32% p<0.001;RV: 24 vs. 10% p=0.001). During inpatient follow-up (median 15 [IQR 6-35] days), in-hospital mortality occurred in 34% with myocardial injury and 44% with LV or RV dysfunction vs. 23% without myocardial injury (p<0.001). Risk for death was greatest among patients with combined myocardial dysfunction and myocardial injury, and less with myocardial injury alone [Figure]. Conclusion Echo-evidenced myocardial dysfunction occurs in nearly three quarters of patients with myocardial injury and is a powerful predictor of in-hospital mortality. [Formula presented]

The prognostic significance of neutrophil-lymphocyte ratio (NLR) in patients with COVID-19

INTRODUCTION: Neutrophil lymphocyte ratio (NLR) is elevated in response to stressful stimuli and has been shown to be associated with poor prognosis in both benign & malignant disorders. Literature regarding NLR as a prognostic marker in COVID19 are limited. Our study was aimed to investigate the relationship between NLR & survival outcomes in patients hospitalized with Coronavirus disease 2019 (COVID19). METHODS: Ours was a single center, retrospective observational study, which included 472 nasopharyngeal swab SARS-CoV-2 RT-PCR positive patients. NLR was derived from the admission complete blood count & was divided into 5 sub-groups as (0-0.99, 1-2.99, 3-9.99, 10-19.99, >20). Demographics, comorbid conditions, and outcomes such as need for mechanical ventilation, length of stay and inpatient mortality were assessed. Statistics were performed using STATA. Significance was assigned at p<0.05. RESULTS: The mean age was 71.16 years in NLR >10 group as compared to 60.3 years in patients with normal NLR 1-2.99. Male patients were found to have much higher NLR than females (65.12% vs 34.88% in NLR 10-19.99, 64.86% vs 35.14% in NLR>20;p-value: 0.05). Among comorbidities, COPD patients were found to have higher NLR (18.92% of NLR>20 vs 10.71% of NLR 1-2.99;p-value:0.02). Rate of endotracheal intubation and need for mechanical ventilation was significantly higher with increasing NLR (0% vs 7% vs 14% vs 17% vs 32%;p-value: 0.03). Inpatient mortality was significantly higher in patients who had NLR>20 (70.27% of NLR>20 vs 16.07% of NLR 1-3 p-value <0.0001). On multivariate regression, patients with NLR>20 had 4 times higher odds of mortality;however, the p-value was not significant (4.07±2.78 p-value: 0.175). CONCLUSIONS: Increasing NLR in COVID19 patients is associated with increased ICU admission, intubation & inpatient mortality. Further studies are warranted to establish NLR, which is readily available & inexpensive, as a potential prognostic indicator in COIVD19 patients.

The prognostic significance of absolute lymphocyte count in patients with COVID-19

INTRODUCTION: The host immune responses try to confront Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with all the potential cells and cytokines. Eventually, natural killer cells and T cells become exhausted, decreasing their counts, leading to lymphopenia. This study aims to assess the clinical utility of the absolute lymphocyte count (ALC) at admission in predicting outcome in patients with COVID-19. METHODS: Ours was a single-center, retrospective observational study, which included 463 nasopharyngeal swabs SARS-CoV-2 RT-PCR positive patients. Absolute lymphocyte count was retrieved from the admission complete blood count & was divided into 3 sub-groups (<500, <1000, and >1000 cells/μL). Demographics, comorbid conditions, and outcomes such as the need for mechanical ventilation, length of stay, and inpatient mortality were assessed. Statistics were performed using STATA. Significance was assigned at p<0.05. RESULTS: 13.82% of patients had ALC count<500, 44.71% had <1000 and 41.25% had more than 1000. Mean age in ALC group<500 was higher (71±1 years vs 65± 1.1 years in ALC group <1000 and 59.9+/-1.3 in ALC group >1000). Profound lymphopenia (<500 cells/μL) was more common in males compared to females (71.88 % vs 28% p value 0.01). ALC count <500, was associated with higher rate of non-invasive (45.31% vs 26.56% for ALC <1000, p-value: 0.01) as well as invasive ventilation (26.5% with ALC <500 vs 19% with ALC <1000 vs 10.4% with ALC with >1000;p-value: 0.01). Inpatient mortality was significantly higher in cohort with ALC <500 (51.56% with ALC <500 vs 33.3% with ALC <1000 vs 24.08% with ALC >1000;p-value 0.05). On multivariate regression, ALC was not a independent predictor of mortality (ALC<500, OR: 1.56±0.75, p-value: 0.44). CONCLUSIONS: Lymphopenia at admission in COVID19 patients is associated with an increased need for non-invasive & invasive ventilation & inpatient mortality. Currently, clinical trials assessing GM-CSF as a possible therapeutic option is underway.

Can age alone be used as a guide for decision-making in COVID-19 patients? a retrospective study

INTRODUCTION: Coronavirus disease 2019 (COVID- 19) caused by the SARS-CoV-2 virus has emerged as one of the greatest challenges to humanity in recent history. Older people have shown to have poor outcomes in recent studies. Our study looks at the characters and outcomes in patients of different age groups admitted to our center. METHODS: Our study is a single-center, retrospective, observational study of 471 COVID-19 patients (confirmed with a positive nasopharyngeal swab for SARS-CoV2 RT PCR) admitted to our hospital. Patients were divided into 3 groups based on Age (0-45 years, 46-65 years, and >65 years). Demographic characteristics and in-hospital outcomes were compared between these groups. STATA was used to perform statistics. Statistical significance was assigned at p=<0.05. RESULTS: 471 patients were included in the study of which 79 (16.77%), 159 (33.76%), and 233 (49.47%) belonged to the age group of 0-45 years (Group A), 46- 65 years (Group B) and >65 years (Group C) respectively. On comparison of pre-existing comorbidities, patients in group B and group C had a higher incidence of baseline comorbidities (Diabetes, Hypertension, Heart failure, COPD rates were 33.96% vs 43.1%, 55.35% vs 81.12%, 9.01% vs 20.59%, 2.5% vs 11.21% respectively). On comparing in-hospital outcomes, the mean time to mechanical ventilation from admission was 3.25 (±1.31) days, 2.42 (±0.68) days and 2.75 (±0.53) days for group A, B and C respectively. 74 (15.71%) patients required intubation during hospitalization of which 7.5%, 32.5%, and 60% belonged to groups A, B, and C respectively. The overall mortality rate among intubated patients was 90.54% among which 8.15%, 31.08%, and 60.81% belonged to groups A, B, and C respectively. The inhospital mortality rate was 32.48% of which 3.27%, 17.65%, and 79.08% belonged to groups A, B, and C respectively. In-hospital mortality rate for group A, B and C were 6.33%, 16.98% and 51.93% respectively (p <0.0001). However, on multivariate regression analysis, age was not an independent predictor of in-hospital mortality for any age group. CONCLUSIONS: Patients >65 years of age have higher co-morbidities and worse in-hospital outcomes. However, age is not an independent predictor of mortality and each patient should be evaluated individually while making an important treatment decision.

The prognostic significance of lymphocyte-to-crp ratio (Lcr) in patients with COVID-19

INTRODUCTION: Systemic inflammation elicited by a cytokine storm is considered a hallmark of coronavirus disease 2019 (COVID-19). This study aims to assess the clinical utility of the lymphocyte-to-C-reactive protein (CRP) ratio (LCR), typically used for gastric & colorectal cancer prognostication. METHODS: Ours was a single center, retrospective observational study, which included 321 nasopharyngeal swab SARS-CoV-2 RT-PCR positive patients. LCR was derived from the admission complete blood count & was divided into 2 sub-groups (<99.99 vs >100). Demographics, comorbid conditions, and outcomes such as need for mechanical ventilation, length of stay and inpatient mortality were assessed. Statistics were performed using STATA. Significance was assigned at p<0.05. RESULTS: LCR <99.99 group had more elderly patients as compared to LCR >100 group (67.74% vs 54.01% of patients >60 years of age). Male patients were found to have lower LCR than females (60.75% vs 39.25% with LCR <99.99;p-value: 0.03). Among comorbidities, patients with history of cancer were found to have higher LCR (7.53% of LCR <99.99 vs 13.24% of LCR >100;p-value:0.03). Lower LCR was associated with higher rate of non-invasive (36.56% with LCR <99.99 vs 19.12% with LCR >100;p-value: 0.01) as well as invasive ventilation (17.74% with LCR <99.99 vs 11.76 with LCR >100;p-value: 0.01). Inpatient mortality was significantly higher in patients who had LCR <99.99 (39.25% with LCR <99.99 vs 22.63% with LCR >100;p-value <0.03). On multivariate regression, patients with LCR <99.99 had 2 times higher odds of mortality;however, this finding did not reach statistical significance. (2.27± 0.81 p-value: 0.15). CONCLUSIONS: Decreasing LCR in COVID19 patients is associated with increased need for non-invasive & invasive ventilation & inpatient mortality. Further studies are warranted to establish LCR, which is readily available & inexpensive, as a potential prognostic indicator in COIVD19 patients.

Outcomes of novel coronavirus disease in patients with diabetes mellitus: A retrospective analysis

INTRODUCTION: Coronavirus disease 2019 (COVID-19) is a multisystem infection caused by SARS-CoV-2 Virus. Recent studies have demonstrated poor outcomes in patients with diabetes mellitus (DM). We sought to assess the in-hospital outcomes of COVID19 patients with DM at our centre. METHODS: Ours was a single centre, retrospective, observational study of 470 COVID-19 patients admitted to our hospital. We divided these patients into 2 groups;those with DM and those without. We compared demographic characteristics, comorbid conditions, and in-hospital outcomes between the two groups. Statistics were performed using STATA. Statistical significance was assigned at p<0.05. RESULTS: Out of the 470 patients included in the study, 35.53% of patients had DM. Mean age of patients with and without DM was 68.35years±1.08 vs 61.71±1.05years respectively. 8.72% of patients were on pharmacological therapy. The diabetic cohort had a higher prevalence of hypertension, heart failure compared to the non-diabetic cohort (88.02 vs49.5% p-value:0.004, 22.9% vs 9.31% p-value: 0.04). Other comorbidities such as OSA, CKD, COPD, Asthma were comparable between both groups. The DM group had a higher level of inflammatory markers during the course of hospitalisation (D-dimer 3802.68± 1499 vs 3448.13 ±1139, CRP: 12.60±0.76 vs 11.85±0.60, ESR: 73.66±10.41 vs 58.04±7.10). The DM group had a significantly higher need for mechanical ventilation (18.56% vs 13.29%, p<0.03), and subsequent in-hospital mortality (43.35% vs 25.74% p<0.05). On multivariate regression, diabetics had 2.64 higher odds of in-hospital mortality, however, the p-value was not significant (Write ODDS Ratio and Confidence interval p-value: 0.116). CONCLUSIONS: Overall inpatient mortality was higher in patients with DM, likely driven by an increased need for mechanical ventilation. Our study positively adds to the existing literature that DM is a significant risk factor for higher morbidity and mortality in COVID-19 patients.