Ethnic Differences in Cancer Deaths at Home before and during Pandemic

Introduction Place of death is a metric used for planning and monitoring palliative care (PC). The COVID-19 pandemic has seen a significant increase in cancer deaths at home. Aims To determine whether pandemic increases in the percentage of cancer deaths at home differ by ethnic group Methods Data source: death registrations in England, 2018 to 2021 with underlying cause of death cancer (ICD-10 C00-C97). Ethnic group derived from linked hospital episode data. The age and deprivation distribution across ethnic groups varies and each has a strong independent effect on place of death. so, calculated percentage deaths at home were standardised by these factors to make them comparable. Analysis concentrated on the largest ethnic groups: White, Asian/Asian British (Asian), and Black/African/ Caribbean/Black British (Black). Comparisons were made between time periods by analysis of the ratio of percentages 2020-2021 (COVID-19 Pandemic) vs 2018-2019 (Baseline). Results For each ethnic group the age-standardised percentage of cancer deaths at home significantly increased (P < 0.05) from 2018-2019 to 2020-2021 . Asian: 33.5%, 47.5% . Black: 28.8%, 39.0% . White: 30.7%, 41.2% The ratio of standardised percentage of deaths at home (95% CI) was . Asian: 1.42 (1.36,1.48 ) . Black: 1.35 (1.27, 1.44) . White 1.34 (1.33, 1.35) Conclusions Cancer deaths at home increased by > 10 percentage points during the pandemic for Asians, Blacks and Whites. Significant differences between ethnic groups before the pandemic (2018-19) persisted with Asians more likely than Whites, and Blacks less likely than Whites to die at home. The largest increase was for Asians, the group with the highest pre-pandemic home deaths. Impact These ethnic differences merit investigation regarding cultural preferences, access issues and quality of PC experience. Community health and PC teams need additional resources and training in culturally sensitive care to support the increased number of ethnically diverse cancer patients dying at home.

BRINGING HEALTHCARE TO PATIENTS' HOMES - DESCRIPTION OF A MOBILE INTEGRATED HEALTH PROGRAM IN DETROIT, MICHIGAN

STATEMENT OF PROBLEM/QUESTION: The United States healthcare system is plagued by rising healthcare costs, variable care quality and patient outcomes, and highly fragmented service delivery with many transitions of care. Mobile integrated healthcare (MIH) programs can add value by bringing healthcare to patients' homes. DESCRIPTION OF PROGRAM/INTERVENTION: The aim of our MIH program is to bring medical resources to patients' homes to increase the availability and intensity of medical care at vulnerable times, during which patients have high risk of escalation of care to an emergency department (ED) or hospitalization. Patients must be age ≥17, live within a 3-county area, and have medical needs that require significant surveillance or would otherwise necessitate hospitalization. Once referred, a MIH paramedic (MIH-P) schedules and performs an in-home visit. MIH physicians are available for phone or video consultation. Primary exclusions include unsafe living environment or homelessness and active substance use disorder. Insurance is not a consideration. The program received an initial startup grant from Blue Cross Blue Shield and financial support for operations is primarily provided by Henry Ford Health System. MEASURES OF SUCCESS: Outcome measures are tracked with an interactive dashboard. Process measures include time from referral to patient visit, percent of competed referrals, number of interventions performed during home visits. Key outcome measures include number of subsequent ED visits and hospitalizations. FINDINGS TO DATE: From April 20, 2020 to December 31,2021, the MIH program received 4979 referrals and completed 3264 initial appointments (65.6% of referrals received) with a total of 5528 encounters completed. Referrals came from providers in the ED (42.3%), internal medicine inpatient and outpatient (27.2%), family medicine (4.1%), a COVID monoclonal antibody infusion program (18.6%), and medical/ surgical specialists (7.2%). Average travel time was 20.3 minutes and average time on scene was 69 minutes. Approximately 55.2% of patients had an estimated income of ≤ $41,000 based on US Census data. About 44.1% of patients were age ≥ 70. Patients were 49.7% non-Hispanic Black, 36.8% non-Hispanic White, 1.8% Asian/ Middle Eastern, 0.2% Hispanic, 11.4% other/ unknown/ declined. Of all MIH encounters, there was a 23.7% ED visit rate within 90 days (34% within 7 days, 30% 8-30 days, 36% 31-90 days) and a 10.5% hospitalization rate within 90 days (40% within 7 days, 24% 8-30 days, 36% 31-90 days). KEY LESSONS FOR DISSEMINATION: Implementation and success of our MIH program relied on a group of dedicated paramedics, health system investment, and continued outreach to referring providers. Promoting sustainability will require continued efforts to demonstrate value of the program and to obtain reimbursement for the valuable and unique services provided by MIH.

Hypercapnia Increases ACE2 Protein Expression and Pseudo-SARSCoV- 2 Virus Entry in Airway Epithelial Cells by Augmenting Cellular Cholesterol

Rationale: Individuals with COPD who develop COVID-19 are at increased risk of hospitalization, ICU admission and death. COPD is associated with increased airway epithelial expression of ACE2, the receptor mediating SARS-CoV-2 entry into cells. Hypercapnia commonly develops in advanced COPD and is associated with frequent and potentially fatal pulmonary infections. We previously reported that hypercapnia increases viral replication, lung injury and mortality in mice infected with influenza A virus. Also, global gene expression profiling of primary human bronchial epithelial (HBE) cells showed that elevated CO2 upregulates expression of cholesterol biosynthesis genes, including HMGCS1, and downregulates ATP-binding cassette (ABC) transporters that promote cholesterol efflux. Given that cellular cholesterol is important for entry of viruses into cells, in the current study we assessed the impact of hypercapnia on regulation of cellular cholesterol levels, and resultant effects on expression of ACE2 and entry of Pseudo-SARS-CoV-2 in cultured HBE, BEAS-2B and VERO cells, and airway epithelium of mice. Methods: Differentiated HBE, BEAS-2B or VERO cells were pre-incubated in normocapnia (5% CO2, PCO2 36 mmHg) or hypercapnia (15% CO2, PCO2 108 mmHg), both with normoxia, for 4 days. Expression of ACE2 and sterol regulatory element binding protein 2 (SREPB2), the master regulator of cholesterol synthesis, was assessed by immunoblot or immunofluorescence. Cholesterol was measured in cell lysates by Amplex red assay. Cells cultured in normocapnia or hypercapnia were also infected with Pseudo SARS-CoV-2, a Neon Green reporter baculovirus. For in vivo studies, C57BL/6 mice were exposed to normoxic hypercapnia (10% CO2/21% O2) for 7 days, or air as control, and airway epithelial expression of ACE2, SREBP2, ABCA1, ABCG1 and HMGCS1 was assessed by immunofluorescence. SREBP2 was blocked using the small molecules betulin or AM580, and cellular cholesterol was disrupted using MβCD. Results: Hypercapnia increased expression and activation of SREBP2 and decreased expression of ABC transporters, thereby augmenting epithelial cholesterol levels. Elevated CO2 also augmented ACE2 expression and Pseudo-SARSCoV- 2 entry into epithelial cells in vitro and in vivo. These effects were all reversed by blocking SREBP2 or disrupting cellular cholesterol. Conclusion: Hypercapnia augments cellular cholesterol levels by altering expression of cholesterol biosynthetic enzymes and efflux transporters, leading to increased epithelial expression of ACE2 and entry of Pseudo-SARS-CoV-2 into cells. These findings suggest that ventilatory support to limit hypercapnia or pharmacologic interventions to decrease cellular cholesterol might reduce viral burden and improve clinical outcomes of SARSCoV- 2 infection in advanced COPD and other severe lung diseases.

COVID-19 VACCINATION IN AN INNER-CITY UROLOGY POPULATION FROM SEPTEMBERdOCTOBER 2021

INTRODUCTION AND OBJECTIVE: New Jersey has the fourth highest death rate due to COVID-19 in the United States over the past year and a half. As of October 2021, 66% of the New Jersey population has been fully vaccinated against COVID-19. The objective of this study is to examine the demographics and rate of vaccination of patients in an underserved, inner-city urology clinic population in Newark, New Jersey. METHODS: Anonymous surveys were distributed during urology clinics in Newark recording patient's age, sex, race, insurance status, reason for clinic visit, other medical problems, previous COVID infection, infection of family members with COVID, COVID vaccination status and type, reasons for forgoing the vaccine, and likelihood of receiving the vaccine in the future. Data from 246 surveys administered from 9/27/2021 - 10/25/2021 was compiled and analyzed with descriptive statistics. RESULTS: 78% of the clinic patients were men of the average age of 60. The population was primarily patients of Hispanic (45.9%) and African American (41.9%) descent. 9.3% of patients were white, 1.5% asian, and 1.5% “other”. 55.2% of patients had managed medicaid, 15.4% had medicare, 16.7% were uninsured, 12.2% had charity care, and 0.4% were incarcerated. Many patients never had a COVID-19 infection (79.7%) and neither did any of their family members (79.3%). 78.5% of patients received a COVID vaccination, the most popular one being Moderna (47.4%) followed by Pfizer (44.9%), and Johnson & Johnson (7.7%). Of the 21.5% of patients who were not vaccinated, 55.8% did not plan to receive the vaccine, 30.8% were unsure, and 13.4% said they would in the future. When asked about their reasons for deferring the vaccine, 61.5% of unvaccinated patients expressed concern about the vaccine's short term side effects, long term side effects or a combination of the two. The other 38.5% reported wanting to wait to see how others responded to the vaccine, reported lack of information about the vaccine, mentioned wanting to avoid unnecessary medication, believed they didn't need the vaccine, or were unable to register for it. The unvaccinated patients were predominantly African American (48.1%), male (76.9%), and of the average age of 51. 80.8% of unvaccinated patients never had covid and for 82.7%, neither did any of their family members. CONCLUSIONS: COVID-19 vaccine reluctance continues to be a national issue. We were encouraged by the higher than expected vaccination rates in our clinic. Further measures should be taken to elucidate the perceived side effects of the COVID-19 vaccine to encourage vaccine use.

Venous thromboembolism among medicare beneficiaries hospitalized with acute ischemic stroke with and without history of COVID-19

Introduction: Venous thromboembolism (VTE) is a common medical complication following acute ischemic stroke (AIS). Studies have suggested that VTE rates were higher among patients with a history of COVID-19. We examined the risk of VTE in AIS patients with and without a history of COVID-19 among Medicare beneficiaries. Methods: We identified Medicare fee-for-service (FFS) beneficiaries aged ≥65 years with AIS hospitalizations from 04/01/2020 to 06/30/2021. COVID-19 cases were identified by the first diagnosis of COVID-19 on a claim at any health care setting. We defined AIS with COVID-19 if the dates of COVID-19 diagnoses were earlier than AIS admission dates. To identify VTE for each AIS admission, we used the following secondary diagnoses codes: ICD-CM-10: I80, I81, I82, I26. We compared the prevalence ratio (PR) of VTE between AIS patients with and without a history of COVID-19. Results: Among 178,830 Medicare FFS beneficiaries with AIS admissions, 6.1% had a history of COVID-19 and 2.6% had VTE as a complication. VTE prevalence among AIS patients with a history of COVID-19 was 3.98% (95% confidence interval (CI), 3.62-4.36%) and 2.53% (95% CI, 2.46- 2.61%) among patients without a history of COVID-19. The adjusted PR of VTE was 1.55 (95% CI, 1.40-1.70, p<0.001) comparing AIS admissions with a history of COVID-19 and those without a history of COVID-19. Non-Hispanic Black patients had the highest VTE prevalence, 6.14% among those with a history of COVID-19 and 3.89% among those without a history of Covid-19, as compared to other race/ethnicity groups. Both Non-Hispanic White and non-Hispanic Black patients with a history of COVID-19 had >50% increased risk of VTE than those without a history of COVID-19 (Adjusted PR, 1.59, 95% CI, 1.42-1.78 for Non-Hispanic White, 1.58, 95% CI, 1.28-1.94 for Non-Hispanic Black, p<0.001). Conclusion: AIS patients with a history of COVID-19 had an increased risk of VTE compared with patients without COVID-19. Healthcare professionals should be aware of the increased risks of VTE among AIS patients with COVID-19 and implement protocols for early VTE prevention.

COVID-19 PEDIATRIC PATIENTS IN THE UNITED STATES;AFRICAN AMERICAN AND HISPANIC AMONG MOST HOSPITALIZED PATIENTS WITH PERSISTENT GI MANIFESTATIONS

Coronavirus (SARS-CoV-2) has caused a severe outbreak in the United States and theworld, and currently causing a global pandemic. SARS-CoV-2 mostly causes respiratory andgastrointestinal symptoms (GI). Clinical manifestations range from mild cold-like symptomsto more severe diseases such as bronchitis, pneumonia, severe acute respiratory distresssyndrome, multi-organ failure, and even death. Coronaviruses (SARS-CoV-1, MERS-CoV,and SARS-CoV-2) seem to less commonly affect children and cause fewer symptoms andless severe disease in this age group compared with adults. We aimed to study SARS-COV-2 and associated GI symptoms in pediatric patients (<18 years) in the USA. Methods: Weanalyzed data from SARS-CoV-2 positive patients evaluated at healthcare centers and hospitalsin the USA (N=6,639) including at least 208 centers/hospitals between January 20th, 2020,and November 5th, 2020. The US consists of a total pediatric population that exceeds 74.2million. Demographics, comorbidities, and clinical symptoms were collected. Statisticaldescriptive analysis and correlation analyses of symptoms were performed. Results: Of 6,639hospitalized COVID-19 pediatric patients, 2,566 (38.6%) were White, 1,974 (29.7%) wereAfrican Americans, 2,040 (30.7%) were Hispanics and 986 (14.8%) were others. The averageage was 15 years and 51% were male. The most common symptoms in our overall cohortwere fever (43%) and cough (32%). Vomiting (11.5%) followed by diarrhea (9.7%) werethe main GI symptoms (9.7%), particularly in African American children. Conclusion: Wereport that cough and fever are the primary symptoms in hospitalized pediatric COVID-19patients in the US. Vomiting, abdominal pain, and diarrhea were common among thesepatients, with vomiting as the most prevalent GI symptom. Most hospitalized patients (~60%)were from African American and Hispanic minority populations.