The Rising Epidemic of Mass Shootings in the US and Its Association with Gun Legislation, Laws, and Sales

Introduction: Mass shootings pose a considerable threat to public safety. This study aims to (1) assess US mass shootings, firearm-related sales, laws, and regional differences from 2015-2021 and (2) investigate changes in mass shootings and firearm sales before and during the Coronavirus Disease 2019 (COVID-19) pandemic. Method(s): A retrospective review of mass shootings, gun sales, and laws regarding the minimum age required to purchase a firearm within the US from 2015-2021. The 10 states/regions with the greatest mean mass shootings/capita from 2015-2021 were selected for further analysis. Result(s): Mass shootings correlated significantly with firearm sales from 2015-2021 nationwide (p< 0.02 for all). The growth in mass shootings, the number killed/injured, and gun sales were greater in 2020 and 2021 compared withthe years prior. The 10 states with the highest mean mass shooting/capita over the study period were Alabama, Arkansas, the District of Columbia, Illinois, Louisiana, Maryland, Mississippi, Missouri, South Carolina, and Tennessee. No significant correlation was found between the number of mass shootings/capita and the minimum age to purchase a firearm. Conclusion(s): Firearm sales correlated significantly with mass shootings from 2015-2021. Mass shootings and gun sales increased at greater rates during the COVID-19 pandemic compared withthe years before the pandemic. Mass shootings exhibited inconsistent trends with state gun laws regarding the minimum age to purchase a firearm. Future studies may consider investigating the methods by which firearms used in mass shootings are obtained to further identify targets for prevention.

The battle over state lines: Leveraging an interstate compact to ensure continuity of care

Background: As a result of COVID-19-related precautions, states temporarily relaxed certain restrictions on telehealth services during the pandemic, including waiving licensing requirements so physicians could serve patients across state lines, but many states ended this flexibility in 2021. According to two online surveys fielded by the Cystic Fibrosis Foundation (CFF) to accredited centers in 2020 and 2021, 65% of programs reported providing care to patients living in another state. Of these, 18.5% reported that some of their out-of-state (OOS) patients were not able to access telehealth services because of licensure-related issues [1]. CFF Compass fielded 20 calls from people with cystic fibrosis (CF) in 15 states requesting assistance in accessing their OOS care center, accounting for more than 25% of all network adequacy inquiries received during that time. CFF recognized the need for policy change to improve access to OOS care for people with CF. Method(s): In 2021, we interviewed five CF care centers about their experiences with telehealth and OOS licensing. The administrative burden of applying for multiple state medical licenses was a key barrier to providing remote OOS care, and CFF identified the Interstate Medical Licensure Compact (IMLC) as one solution. The IMLC streamlines the licensing application process for physicians who want to practice in multiple states. From January 2021 to March 2022, CFF supported legislation in 10 states to join the IMLC by sending letters with 31 care center director co-signers. CFF also hosted a webinar in June 2021 to educate CF care centers about the IMLC as away to pursue multiple medical licenses with one application. We shared follow-up information about the IMLC through CFF COVID-19 digest emails. CFF sent a survey in March 2022 to all CF care centers to understand current use of and barriers to telehealth for CF care teams. Data from this survey are forthcoming. Result(s): Before CFF's engagement in January 2021, 30 states and the District of Columbia were members of the IMLC. As of April 8, 2022, five additional states have passed legislation to join the IMLC, reflecting a 17% increase in state participation from January 2021 to March 2022. Within the 35 participating states at present,126 CF care center programs will have the potential to use the IMLC. CFF has supported legislation in all six states with pending legislation to join the IMLC in 2022. Increased physician awareness of IMLCwas evidenced by physician participation from 20 states in thewebinar, aswell as broad distribution of the recording via the COVID- 19 digest to 288 CF programs in 49 states afater the session. Conclusion(s): Although more states taking action to join the IMLC is an important step, challenges persist. Even in IMLC member states, CF providers express concerns about the cost and administrative burden of maintaining licenses in multiple states. Permanent regulations regarding use of and reimbursement for telehealth remain uncertain. To better understand current challenges and opportunities for telehealth and remote OOS care, CFF is supporting additional research and advocacy.Copyright © 2022, European Cystic Fibrosis Society. All rights reserved

Mpox Awareness, Risk Reduction, and Vaccine Acceptance among Pwh in Washington, Dc

Background: PWH are disproportionally affected by mpox and at high risk for severe complications. The recent mpox outbreak response included increasing awareness, encouraging behavioral changes and pre- and post-exposure vaccination. We assessed knowledge and perceptions of mpox, adoption of preventive behaviors, and attitudes towards vaccination among PWH in Washington, DC. Method(s): Data from a cross-sectional mpox survey were collected between August and December 2022 from PWH enrolled in a longitudinal HIV cohort, the DC Cohort. We conducted uni- and bivariable analyses comparing participants by vaccination status (vaccinated, plan to vaccinate, no plan to vaccinate) and by HIV risk group (MSM vs. non-MSM). We conducted multinomial regression to identify factors associated with vaccine acceptance. Result(s): Among 178 PWH completing the survey (median age 55;71% male, 81% non-Hispanic Black, 37% MSM), 162 (91%) had heard of mpox. Among 159 PWH who had heard of mpox and answered vaccination questions, 21% (n=33) were vaccinated, 43% (n=69) planned to vaccinate and 36% (n=57) did not plan to vaccinate. Comparing the 3 groups, significant differences were observed by age, gender, education, income, HIV risk group, and level of worry about mpox (all p< 0.01). Viral suppression, prior COVID and influenza vaccination, access to STI services, and STI diagnoses in the last year were not associated with vaccine status. Behaviorally, a higher proportion of vaccinated participants reported limiting their number of sexual partners (p< 0.001) and using more preventive behaviors (e.g., limiting gatherings, increased condom use, avoiding skin-to-skin contact;p=0.034) in response to mpox. A higher proportion of MSM reported limiting their number of sexual partners compared to non-MSM (33% vs 7%, p< 0.0001) and were more likely to be vaccinated or plan to vaccinate vs non-MSM (p< 0.001). In adjusted multinomial regression models comparing vaccinated PWH and those planning to vaccinate to those not planning to vaccinate, age (p= 0.0231) and HIV risk factor/gender (p< 0.0001) were significantly associated with vaccination status with younger PWH and MSM more likely to vaccinate (Figure). Conclusion(s): High levels of mpox awareness were observed among this cohort of PWH in Washington, DC with more MSM employing risk reduction behaviors and vaccination as mpox prevention strategies. Ensuring that all PWH, regardless of gender, sexual orientation, or age, understand the risks of mpox may improve vaccination uptake.

Kaiser Permanent (Kp) Mid-Atlantic States (Mas) Experience with Covid Related Hospital Admissions in Adult Patients with Myositis

Background. Myositis is a group of rare systemic disease and may be treated with immunosuppressives which increase the risk for poor outcome with the COVID19 pandemic. Patients with this condition may have higher rates of admission to the hospital. Methods. KP is a health insurance plan and provides care to about 800 thousand people (including Medicare and Medicaid population) in Maryland, District of Columbia and Northern Virginia. As part of quality improvements, we randomly looked at 40 patients from our larger cohort with myositis who are diagnosed and followed by a board-certified rheumatologist. We noted hospitalizations and Covid infection from March 1, 2020 to December 31, 2021. Results. Of the 40 patients, 29 (72%) were female and 11 were male. 19 (47%) were Blacks, 18 whites (including 6 Latino), and 3 Asians. Age ranged from 25 to 80 years with a mean age of 59.6 years. 25 (62%) patients had Dermatomyositis, 14 had polymyositis and 1 was IBM. The mean age at diagnosis was 55.9 years (range 23-80 years). 12 (30%) had myositis specific antibodies (4 Jo-1, 4 Mi-2, 1 PL 7, 1 PL 12, 1 PL7 plus PL12, 1 TIF Gamma). 22 (55%) were negative. Six did not have antibody testing. During this time, 11 (27.5%) were admitted to the hospital, 2 patients tested positive for COVID 19. One tested positive in the hospital and was asymptomatic. The other person was admitted for symptomatic COVID 19 infection. Other reasons for admission were cardiac, pulmonary (noncovid 19 related), infections, Gastrointestinal issues (including GI bleeding). One admission was for accidental bleach ingestion, and one for psychiatric admission. Of these 40 patients, 38 (95%) patients have received the COVID vaccinations, one patient refused, and for one person we do not have any record of vaccination. Conclusion. The admission rates to the hospital do appear to be higher for this group of patients with myositis, as is generally postulated. However, the reasons for admission were largely related to reasons other than COVID 19 infection and were related to general medical conditions.

Trends in Palliative Care Consultations in COVID-19 Patients Over Course of Pandemic (Sci257)

Outcomes: 1. Compare characteristics and clinical outcomes of inpatients with COVID receiving palliative care consultation (PCC) versus those who did not. 2. Elucidate evolution of PCC interventions over trajectory of successive COVID surges. Background/objectives: Palliative care (PC) teams have played an integral role in the care of critically ill patients hospitalized with COVID-19. This study describes how an inpatient, hands-on palliative care team adapted as the viral characteristics of the disease evolved. Method(s): Retrospective chart review of 2,879 patients, hospitalized with a primary diagnosis of COVID-19, at a large, urban academic hospital in Washington, DC from March 2020 through March 2022. Data was collected on baseline demographics, clinical characteristics, hospital course, and palliative care consultations (PCCs). Results were compared between patients receiving PCCs and those who did not. Trends in results were studied across the region's three surge periods, "Initial" (March 2020 to June 2020), "Delta" (November 2020 to April 2021), and "Omicron" (December 2021 to January 2022). Result(s): In-hospital mortality declined over the Initial, Delta, and Omicron surges with mortality rates of 17.5% (n=137), 13.6% (n=121), and 11.2% (n=62), respectively. ICU admission rates declined, with 21.6% (n=169), 21.3% (n=189) and 17.0% (n=94) for each of the surges. 393 (13.7%) patients received a PCC, with consult rates of 12.7%, 12.1%, and 14.3% for each surge, respectively. In-hospital mortality for PCC patients was 47.8% (41.1%, 51.2%, 40.9% by surge) vs. 9.3% for non-PCC (14.2%, 7.3%, 5.6%). Majority of PCC patients had COPD in Initial (87.4%, n=83) and Delta (93.7%, n=119) surges (14.8%, n=13 for Omicron). As hospital staff became acclimated to the pandemic and the sense of urgency declined, the days to PCC increased (7.1, 8.8, 10.1 days, respectively). During the Initial surge, the primary PCC interventions were for symptom management (28.5%, n=290), psychosocial support (18.9%, n=193), and goals of care (14.9%, n=152). Psychosocial support (13.5%, n=172) and goals-of-care (6.3%, n=80) interventions declined during the less acute Omicron surge (13.5%, n=172), while symptom management increased (38.2%, n=488). Conclusion(s): The demographic profile and viral characteristics of COVID-19 patients changed over the course of the pandemic, impacting both patient outcomes and palliative care's interdisciplinary response to the needs of patients and families.Copyright © 2023

Preferences for social risk factor screening among breast and prostate cancer survivors in the Washington DC region: A qualitative study

Despite improvements in cancer outcomes over time, significant disparities remain between Black and White cancer survivors. Medical care is estimated to account for 10-20% of health outcomes, while other modifiable factors explain as much as 80-90% of outcomes. These disparities may thus be driven by multiple factors including social determinants of health, differences in treatment or follow up, or attitudes and behaviors of care teams. As part of a larger project, we conducted a qualitative study to understand cancer survivor preferences for and experiences with social needs screening and referrals. The results of this assessment will inform the delivery of social risk screening for breast and prostate cancer survivors in the multi-site study. Semi-structured interviews were conducted in English between March and April 2022 with breast and prostate cancer survivors from two cancer institutes in Washington DC. Patients were purposively recruited to ensure diversity in age, race, and cancer stage (I-III). Each interview lasted 60 minutes. Transcripts were reviewed for consensus and preferences for social needs screening. Thirteen survivors participated in the interviews. Participants were mostly breast cancer survivors (n=10), African American (n=6), were equal in stages I and II at time of diagnosis (n=5), and ranged in age from 34 to 81 with a median age of 64. Most patients (n=7) did not report social needs screening during their treatment, though all patients welcomed having these conversations with their care team. The majority of patients (n=9) desired face-to-face conversations as opposed to on paper (n=1) or through the patient portal (n=1). Similarly, most patients (n=7) did not mind who on their care team held the conversations. There was difference in opinion on how often social needs should be discussed, with four participants suggesting every appointment to another patient suggesting once at diagnosis. When asked about the needs patients experienced during treatment, food insecurity and nutrition were most cited (n=6), followed by transportation (n=4) and emotional resources (n=4). Only one patient reported not desiring social needs referrals during treatment. Other avenues for seeking out social resources included self-initiated research online or through books (n=2), and another patient described utilizing their local church (n=1). Finally, patients also spoke about challenges in receiving treatment and transitioning to survivorship due to the COVID-19 pandemic, including hospital staff turnover and care team inconsistency (n=1), bringing loved ones to appointments (n=1), and transportation challenges for individuals who relied on public transport to and from the clinic (n=1). This research reveals important insight to the perspective on social needs screening among a group of breast and prostate cancer survivors in the Washington DC region and highlights the ways in which patients have experienced and desire screening for social needs. In future work we will expand the number of interviews and apply these findings into practice.

Elevated COVID-19 Case Rates of Government Employees, District of Columbia, 2020-2022.

OBJECTIVES: To estimate the rate ratio (RR) of reported Coronavirus Disease 2019 (COVID-19) cases among governmental employees from seven District of Columbia (D.C.) departments from March 2020 to February 2022. METHODS: Poisson regression models were used to estimate the RR by department, using D.C. residents as the reference and the person-day as the offset. The COVID-19 surveillance data and the full-time equivalent hours for each department were obtained from the D.C. governmental websites. RESULTS: Five of the seven departments had statistically significant higher COVID-19 case rates than D.C. residents. Stratified by four pandemic stages, RR of Fire and Emergency Medical Services (FEMS), Office of Unified Communication (OUC), and Metropolitan Police Department (MPD) were consistently >1: FEMS: 3.34 (95% confidence interval, CI [2.94, 3.77]), 2.39 (95% CI [2.06, 2.75]), 2.48 (95% CI [2.06, 2.95]), and 3.90 (95% CI [3.56, 4.26]), respectively; OUC: 1.47 (95% CI [0.92, 2.18]), 2.72 (95% CI [1.93, 3.69]), 1.85 (95% CI [1.09, 2.92]), and 2.18 (95% CI [1.62, 2.85]), respectively; and MPD: 2.33 (95% CI [2.11, 2.58]), 1.96 (95% CI [1.75, 2.18]), 1.52 (95% CI [1.29, 1.77]), and 1.76 (95% CI [1.60, 1.92]), respectively. CONCLUSIONS: The results suggested higher case rates for emergency responders and frontline personnel than for general population in D.C.

Selection of appropriate inpatients for outpatient parenteral antimicrobial therapy (OPAT) during the COVID pandemic

Background. Providing a safe discharge in patients appropriate for outpatient parenteral antimicrobial therapy (OPAT) became an important focus of the inpatient to outpatient transition during the pandemic. Hospital beds were needed for ill patients with COVID;transfers in and out of facilities and interfacility infection became issues for long-term care (LTCF) and short-term nursing facilities (SNFs) in the US during the pandemic. We examine the traditional barriers, including age, and outcomes of patients selected for OPAT initiation during the pandemic period. Methods. Washington DC VAMC (WDVAMC) is an urban medical center with 220 acute and LTC beds. At the start of the pandemic, a multidisciplinary OPAT program was initiated and led by ASP Nurse Practitioner (NP), supported by ASP Pharmacist and ASP/ID Physician. OPAT included care continued at home, SNF, LTC and hemodialysis locations;the OPAT program focus was on appropriate selection, post-discharge safety monitoring, outpatient follow-up at completion, tracking and outcome determination (30D, 90D readmissions). OPAT related readmissions related to drug or opat-indicated infections. Results. BetweenApril 2020-2022, 157 uniqueOPAT discharges (10.4OPAT/1,000 admissions 2020 and 4.8OPAT/1,000 admissions 2021);themajority were offeredOPAT at home (47%).Mean durationOPAT22+/-13days over that period;most frequent indication osteomyelitis and BSI. OPAT related readmissions were infrequent at 30D (7%) and 90D(1%).The meanage was 67+/-13y with 5%>90yrs, 21%>75yrs and 58%>65yrs. In the pandemic 92% completed OPAT;compared to younger group those >75y, rates of completion (93%vs 92%, P=NS) and mean duration of OPAT were similar however amodest increase in 90D OPAT-related readmission (1.2% vs 0%, P=0.04). The only two deaths prior to completion of OPAT occurred in those >75y. Conclusion. Transitions to OPAT are required for serious infections in hospitalized patients of all ages, however transitions to SNF and LTC were limited at times during the pandemic. We found OPAT can be delivered safely, regardless of age during a pandemic state with careful coordination between stakeholders and a systematic process to monitor outcomes and track patients, particularly for the elderly.

Utility of a Test-to-Return Strategy to Identify Individuals With Coronavirus Disease 2019 (COVID-19) in the Prekindergarten Through Grade 12 School Setting-District of Columbia, January 2022.

The highly transmissible severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron variant led to increased hospitalizations, staffing shortages, and increased school closures. To reduce spread in school-aged children during the Omicron peak, the District of Columbia implemented a test-to-return strategy in public and public charter schools after a 2-week break from in-person learning.

DC COVID Connect: Helping Children •Families Navigate COVID-19 Response Efforts with a Mobile Application in Washington, DC

Background: During the initial days of the COVID-19 pandemic in March 2020, medical students at The George Washington University School of Medicine •Health Sciences (GWU SMHS) sought to address the rapid dissemination of misinformation by creating DC COVID Connect (DCC), a reliable web-based resource specific to the Washington, D.C Metropolitan area. With the emphasis on clinical public health in the GW SMHS M.D. Program curriculum, these students were well-equipped to consolidate a comprehensive body of information to help members of all ages in the local community navigate all aspects of their lives during the pandemic. Methods: The online resource was originally a 130-page html document. Sections of the document include but are not limited to: age-group specific health information about COVID-19, local news updates in the DMV pertaining to COVID19, information for at-risk populations: individuals experiencing homelessness, incarceration, and disability, peer-reviewed research, services (housing, legal services, etc). To better disseminate these resources, our team transformed the document into a website, available in 12 different languages.The DCC team is now in the process of launching a mobile application with a database connected to the website for a more user-friendly interface for the pediatric population. The app prioritized: certain age-appropriate sections relating to emerging vaccine guidelines for younger populations, educational resources, and sexual and reproductive health topics. Results: The DCC team began with 60 fourth-year medical students and grew to include over 100 medical students with guidance from physician/resident mentors. DCC has been recognized as a trusted resource by the community and has been utilized by D.C. Medicaid, the Black Coalition Against COVID, “El Tiempo Latino”, and providers at local hospitals and clinics including Children's National Medical Center (CNMC). In the past several months, we have collaborated with the providers at CNMC and plan to launch the app in August 2021. QR code badges will be used to facilitate distribution among patients and families. Our Google Analytics report showed that DCC had a total of 13,332 users since the launch in July 2020. With additional data regarding user demographics from QR code tracking and surveys, we hope to utilize this information to increase accessibility of our resource. Conclusion: The framework of the DCC app provides the much needed infrastructure that is lacking in the DC community by keeping pace with the breadth of information and resources that are being made available to our pediatric population. The impact of the pandemic will linger for years to come and our resource will continue to evolve and repurpose the work that we do to reflect such changes.

DIARRHEA, ELEVATED AST, AND ELEVATION OF INFLAMMATORYRELATED BIOMARKERS IS A PREDICTOR FOR MORTALITY IN MINORITY HOSPITALISED COVID-19 PATIENTS

Background and Aims: Initial reports on US COVID-19 showed different outcomes in different races. In this study, we use a diverse large cohort of hospitalized COVID-19 patients to determine predictors of mortality. Methods: We analyzed data from hospitalized COVID- 19 patients (n=5,852) from 8 hospitals. Demographics, comorbidities, symptoms and laboratory data were collected. Results: The cohort contained 3,662 (61.7%) African Americans (AA), 286 (5%) American Latinx (LAT), 1,407 (23.9%), European Americans (EA), and 93 (1.5%) American Asians (AS). Survivors and dead patients' mean ages were 58 and 68 for AA, 58 and 77 for EA, 44 and 61 for LAT, and 51 and 63 for AS. Mortality rates for AA, LAT, and EA were 14.8%, 7.3%, and 16.3%. Mortality increased among patients with the following characteristics: age, male gender, New York region, cardiac disease, COPD, diabetes mellitus, hypertension, history of cancer, immunosuppression, elevated lymphocytes, CRP, ferritin, D-Dimer, creatinine, troponin, and procalcitonin. Use of mechanical ventilation, respiratory failure, shortness of breath (SOB) (p<0.01), fatigue (p=0.04), diarrhea (p=0.02), and increased AST (p<0.01), significantly correlated with death in multivariate analysis. Male sex and EA and AA race/ethnicity had a higher frequency of death. Diarrhea was among the most common GI symptom amongst AAs (6.8%). When adjusting for comorbidities, significant variables were age (over 45 years old), male sex, EA, patients hospitalized in Indiana, Michigan, Georgia, and District of Columbia. When adjusting for disease severity, significant variables were age over 65 years old, male sex, EA as well as having SOB, elevated CRP, and D-dimer. Glucocorticoid usage was associated with an increased risk of COVID- 19 death in our cohort. Conclusion: Among this large cohort of hospitalized COVID-19 patients enriched for African Americans, predictors of mortality include male gender, diarrhea, elevated AST, comorbidities, respiratory symptoms and failure, and elevation of inflammatory- related biomarkers. These findings may reflect the extent of systemic organ involvement by SARS-CoV-2 and subsequent progression to multi-system organ failure. High mortality in AA in comparison with LAT is likely related to a high frequency of comorbidities and older age among AA.

THE PUBLIC HEALTH IMPLICATIONS OF EXPANDING U.S. ALCOHOL HOME DELIVERY LAWS

Purpose: During the COVID-19 pandemic, many states expanded online alcohol sales and directto- consumer home delivery and shipping laws. Given that expanding access to and availability of alcohol in general is harmful to youth and adults, it is important to track these new laws and understand their impacts. This presentation will: (1) discuss the expansion of alcohol home delivery laws across the U.S.;and (2) assess the drinking patterns and behaviors of adults who reported having alcohol delivered to their homes. Method: (1) An inter-disciplinary team studied state alcohol home delivery laws and developed a new policy topic to be tracked by the Substance Abuse and Mental Health Services Administration under the Sober Truth on the Prevention of Underage Drinking (STOP) Act. (2) Along with colleagues at the University of Maryland, Baltimore County and Johns Hopkins Bloomberg School of Public Health, a team of researchers conducted a cross-sectional online survey with a convenience sample of U.S. adults over 21 years old in May 2020 to assess the relation between having alcohol delivered and alcohol consumption. Data: Data were obtained from: (1) Analyzing relevant alcohol-related home delivery statutes and regulations for all states and the District of Columbia. (2) The online survey whose sample included 832 participants - 84% female, 85%White, and 72%ages 26-49. Results: (1) Preliminary results demonstrate that more states expanded current laws or enacted new laws to allow manufacturers and retailers to ship or deliver alcohol directly to consumers' homes by the end of 2021 than had such laws in 2009. (2) Participants who had alcohol delivered reported consuming significantly more drinks (p < 0.001) and drinking on a significantly greater number of days (p < 0.001) than participants who obtained their alcohol in other ways. Conclusions: Alcohol home delivery laws have significantly expanded over the last decade, with many changes occurring during the COVID-19 pandemic. As these laws change to expand consumers' access to alcohol at home, this may result in increased public health harms, including among the underage population. States should consider these public health findings when deciding on the permanency of their alcohol delivery laws.

Knowledge is power: Designing an educational program to support black breast cancer patients

Background. Black women diagnosed with breast cancer are 40 percent more likely to die than their Caucasian peers. They are often diagnosed with higher staged cancers, when treatments are more toxic and costly (Centers for Disease Control, 2018). In addition, Black women have worse stage-specific survival than white women (American Cancer Society, Cancer Facts and Figures for African Americans 2019-2021). Lack of medical knowledge and social isolation are contributing factors to health care disparities. To address these factors, in fall 2019 a member of the board of directors of Living Beyond Breast Cancer approached LBBC to design an educational program for Black patients newly diagnosed with early-stage and metastatic breast cancer. The overarching program goal was to address health care disparities for Black people. The program aimed to increase knowledge about breast cancer and about the implicit and explicit bias Black patients encounter in health care settings, and to provide tools to address it. The program also prepared patients to be informed partners in their health care and connected them to existing resources and to other Black patients for peer support. Methods. LBBC convened an advisory board of ten Black community leaders with expertise in oncology, health care disparities, social and practical support, and advocacy. Most had a personal history of breast cancer. A consultant with expertise in program development and health disparities was hired to oversee the project. The advisory board met monthly to develop content, format, outreach, and speaker recommendations. Initial plans were to deliver the program as a one-day symposium attached to LBBC's fall conference. Because of the COVID-19 pandemic, the advisory board decided to offer the program virtually using a combination of live sessions supplemented with video content. Learnings were intended to prepare participants to more effectively communicate with health care professionals and empower them with practical steps to access appropriate care. An evaluation was designed, and participants received an emailprompting them to offer feedback after each session. Results. The program was delivered from September through October 2020. Speakers were Black oncologists, social workers, researchers, and advocates. The first session was an on-demand video offering guidance to recently diagnosed Black breast cancer patients. Three live sessions were delivered weekly on the topics of identifying barriers to accessing care, early-stage breast cancer treatment, and metastatic breast cancer treatment. The last two sessions focused on self-care and advocacy, with the final session delivered at LBBC's virtual fall conference. LBBC registered 436 people from 36 states and Washington, DC, Canada, and the United Kingdom. Participants ranged from age 27 to 83 and lived in urban, suburban, and rural areas. In all, 307 registrants identified as Black, and 40 reported a breast cancer diagnosis in the last six months. Of participants who completed program evaluations, 75 percent reported an increase in knowledge of breast cancer, 77 percent reported increased understanding of treatment, 82 percent reported increased confidence to have conversations with loved ones or health care providers, and 85 percent said they learned strategies to address implicit and explicit bias. An informal assessment of open-field responses demonstrated that attendees valued the programmatic focus on their unique needs as Black breast cancer patients. Conclusions. An educational program led and designed by Black health care professionals and patients can be successfully delivered in a combination live and virtual content format to improve knowledge, communication skills, and feelings of self-efficacy for Black people with breast cancer.

National Guard Youth ChalleNGe: Program Progress in 2019-2020

The National Guard Youth ChalleNGe program is a residential, quasi-military program for youth ages 16 to 18 who are experiencing academic difficulties and exhibiting problem behaviors inside school, outside school, or both;have either dropped out or are in jeopardy of dropping out of their high school;and, in some cases, have had run-ins with the law. ChalleNGe's stated mission is to "intervene in and reclaim the lives of 16-18-year-old high school dropouts, producing program graduates with the values, life skills, education, and self-discipline necessary to succeed as productive citizens" (National Guard Youth ChalleNGe, 2015, p. 2). Participating states operate the program, which began in the mid-1990s, with supporting federal funds and oversight from state National Guard organizations. At the beginning of 2020, there were 39 sites in 28 states, the District of Columbia, and Puerto Rico (two sites closed during the summer of 2020, but three other sites are in various planning phases). Nearly 250,000 young people have taken part in the ChalleNGe program;roughly 184,000 have completed it. The ChalleNGe program is 17.5 months in length, broken into a 5.5-month residential phase (comprising a two-week acclimation period, called Pre-ChalleNGe, and the five-month ChalleNGe) followed by a 12-month post-residential phase. During the post-residential phase, graduates may continue their education, find employment, enlist in the military, or undertake some combination of these. Each graduate has a mentor whose role is to provide advice, assist with the transition after ChalleNGe, and provide monthly reports back to the program about the graduates placement (i.e., pursuing education, being employed, enlisting in the military, or some combination thereof). Graduates and mentors are expected to meet regularly.

County-level COVID-19 Case Fatality Rate in Medicaid Expansion States Compared to Non-Expansion States

Background. Medicaid expansion has been adopted by 38 states and the District of Columbia,1,2 contributing to lower rates of uninsured individuals in the US.3 During the COVID-19 pandemic, Medicaid enrollment offset employer-based insurance losses precipitated by the recession.4 The aim of this study was to evaluate whether Medicaid expansion may have impacted COVID-19 mortality. Methods. We conducted an ecologic study that included all US counties in the 50 states and District of Columbia. County-specific Medicaid expansion status was based on whether expansion was adopted within the state. COVID-19 cases and deaths for each county were obtained from the Centers of Disease Control (CDC). Unadjusted and multivariable negative binomial regression with robust standard errors to account for clustering of counties within each state were used to evaluate the association of COVID-19 case fatality rate and Medicaid expansion status. Adjusted models included the addition of four sets of county-level covariates thought to influence the association of Medicaid status and COVID-19 fatality rate: demographics, comorbidities, economic indicators, and physician density. These analyses were then performed in subgroups of counties defined by urbanicity (metro, suburban or rural) and quartiles of poverty rates. Incidence Rate Ratios (IRR) and 95% confidence intervals (CI) are reported. Results. A total of 1,814 Medicaid expansion and 1,328 non-expansion counties were included in the analysis. Crude case fatality rates were 2.1% (non-expansion) and 1.8% (expansion). Medicaid expansion was not associated with a significantly lower COVID-19 case fatality rate in either the unadjusted (IRR: 0.86;95% CI: 0.74, 1.01) or fully adjusted (IRR: 1.02;95% CI: 0.90, 1.16) models. In adjusted models, Medicaid expansion status was also not associated with differences in COVID-19 case fatality rate when counties were stratified by either urbanicity or percent of individuals living below the poverty line. Conclusion. In this county-level analysis, Medicaid expansion status was not associated with a significant difference in county-level COVID-19-related case fatality rates among people of all ages. Future individual-level studies are needed to better characterize the effect of Medicaid on COVID-19 mortality.

The financial impact of the COVID-19 pandemic on vein practices in the United States

Introduction, Objectives, and/or Purpose: The AVLS Financial Impact of the COVID-19 Pandemic on Vein Practices Survey Part I and II was conducted to assess the direct and indirect financial impact the COVID-19 pandemic has had on vein practices in the United States. This encompasses the initial impact of the pandemic (including mandated practice closures) as well as the long-term affect the pandemic as had on financial revenue, practice expenses and patient volume. The survey included changes that were made to practices as a result of the pandemic and what if any government assistance programs were utilized. The survey also addressed changes in patient demographics as a result of the pandemic including patient age, types of treatments and clinical stage of venous disease at presentation. Methods: The survey was anonymous, all US based AVLS members were invited to participate. Surveys were conducted through SurveyMonkey Inc. (San Mateo, California). AVLS members were notified through email, social media and MAC postings. 93 members completed part I of the survey, open from June 29 to July 31, 2020. As the impact of the pandemic was projected to extend beyond the dates of the first survey, a second was conducted one year later. Part II of the survey was open from February 23 to May 12, 2021. 74 members participated in Part II. 41 participated in both. The state in which the participant's practice is located was asked along with practice setting, size, length the practice has been open and percentage of time dedicated to the treatment of venous and lymphatic disease. Practice types were defined as hospital owned/affiliated, solo practice, owner/partner of multi-physician practice and employed physician of a non-hospital affiliated practice. Questions covered: practice revenue changes, patient volume changes, practice expenses and measures/changes taken to offset losses including government assistance programs. Participants (Part II) were asked if practice revenue had returned to pre-COVID levels. The survey also asked how the participants were handling vaccination of their staff. Results: All practice settings were represented with the largest number of responses from physicians in solo practice, 67% (63) of Part I participants and 81% (60) of Part II participants. The majority of participants reported being in practice for greater than 10 years and having less than 10 non-physician employees prior to the pandemic. A total of 71 (76%) part I participants and 59 (79%) part II participants identified their practice as devoted more than 75% to the treatment of venous and lymphatic disease. Practices from 33 states including the District of Columbia were represented in the survey responses. Participants of Part 1 of the survey were asked to give their best estimate of the negative financial impact of the Covid- 19 pandemic on their practice's revenue since the beginning of the pandemic. 52% reported a 25-50% decrease, 23% reported a less than 25% decrease, 15% reported a 51-75% decrease and 5% reported a greater than 75% decrease. On Part II of the survey conducted approximately 1 year later 53% of participants reported a 25-50% decrease, 23% reported less than 25% decrease, 15% reported 51-75% decrease, 5.4% reported greater than 75% decrease and 4% reported no financial impact. Participants of the Part 1 portion of the survey were asked to give their best estimate of the impact of the Covid-19 pandemic on their practice's patient volume since the beginning of the pandemic. 43.0% reported a 25-50% decrease, 23.7% reported a 51- 75% decrease, 21.5% reported a greater than 75% decrease, 9.7% reported less than 25% decrease and 2.1% reported no impact on patient volume. On the follow-up portion of the survey conducted approximately one year later 48.7% of participants reported a 25-50% decrease, 31.1% reported less than 25% decrease, 12.2% reported 51-75% decrease, 5.4% reported greater than 75% decrease and 2.7% reported no financial impact. 48.4% of respondent's reported less than 10% increase in expenses on Part I of the survey and 34.4% reported less than 25% increase in expenses as a result of the pandemic on part 1 of the survey. On Part II of the survey 59.5% of respondent's reported less than 10% increase in expenses and 32.4% reported a 10-15% increase in expenses as a result of the pandemic. The majority of practices surveyed reported participating in a government assistance program. The most common program participated in was the Paycheck Protection Program followed by the CARES Act Provide Relief Fund, the Medicare Accelerated and Advance Payment Program and the Economic Injury Disaster Loan. 55.4% of survey respondents reported having to temporarily close their practice. 50.0% reported reduced services and 70% reported reduced hours. 2% reported permanent closure of practice and 39.8% reported postponement of planned practice expansion. 50% of survey participants reported their practice temporarily laid off/furloughed employees. 11% reported temporary layoff/furlough of physicians. 15% reported permanent layoff of employees and 3% reported permanent layoff of physicians. 12% reported employee pay cuts and 55% reported physician pay cuts as a result of the pandemic. A small group of participants reported seeking temporary employment elsewhere and 48% reported delay of hiring new staff. Vein practices also saw a change in patient demographics as a result of the pandemic. On Part II of the survey participants were asked if they had seen any of the below listed changes in their patient demographics compared to before the pandemic. 48.9% reported a decrease in the number of patients over the age of 65. 46% reported a decrease in the number of patients with C2 and C3 disease. 23% reported a decrease in the number of patients with C5 and C6 disease. 56.8% of participants reported a decrease in the number of physician referral's and 41.9% reported a decrease in the number of non-physician patient referrals. 62.2% of practices reported a decrease in cosmetic treatments. Only 10.8% of participants reported no change in patient demographics. On part 2 of the survey conducted approximately 1 year after the start of the pandemic participants were asked if their practice revenue had returned to normal pre-COVID levels. Only 14.9% of participants reported that their revenue had returned to normal. 37.8% reported a 25% decrease in revenue, 28.4% reported a 25-50% decrease in revenue and 10.8% reported a greater than 50% decrease in revenue. 8.1% reported increased revenue compared to pre-pandemic times. 89.2% of survey participants reported that they had received or will receive the Covid-19 vaccine. 10.8% reported no to the question. Survey participants were asked if they would be requiring their staff to receive the Covid-19 vaccine. 13.5% reported yes. 14.9% reported no. 71.6% reported they are not requiring employees to receive the vaccine but they will be encouraging them to do so. Conclusions: The Covid-19 pandemic has had a significant negative financial impact on vein practices in the United States. The negative financial impact of the pandemic has endured for over a year. This decrease in revenue corresponds to a decrease in patient volume. At one year after the start of the pandemic the vast majority of practices surveyed have not returned to a normal practice revenue level. Both the decrease in patient volume and decrease in practice revenue was surveyed to be greater earlier in the pandemic (Part I) This is likely secondary to mandated closures which were more common earlier in the pandemic and thus better captured by the first survey. Most practices participated in some form of government financial assistance and many participated in multiple. Most practices reported an increase in practice expenses related to the Covid-19 pandemic. As a result of the of the pandemic practices have seen changes in patient demographics compared to before the pandemic. The most significant change was a decrease in patients over the age of 65. Decreases in C2 and C3 patients was more common than C5 and C6 patients. During the surveyed time, practices saw both a decrease in the number of physician referrals and non-physician referred patients. There was a significant decrease in the number of cosmetic treatments during the time surveyed.

COVID19 PATIENTS IN A TERTIARY HOSPITAL IN WASHINGTON DC: EFFECTS OF COMORBIDITIES AND GASTROINTESTINAL SYMPTOMS ON OUTCOME

Background: Coronavirus disease 2019 (COVID19) disproportionately struck minority populations.It is important to find out the determinants of such differences in outcomes. Methods:We collected data on 403 hospitalized COVID19 patients at Howard University Hospital.Statistical analysis of symptoms, comorbidities, and lethality was performed using SPSS.Results: There were 257 (63.7%) African Americans (AAs), 102 (25.3%) Hispanics, and 26(6.45%) Whites. The mean age was 55.6 years old (+/-18.5). However, the Hispanic's meanage was the lowest (43.66 years vs. 61.23 for Whites vs. 60 for AAs). 64 (15.8%) patientsdied. Age and race were risk factors for poor outcomes. Elevated Creatinine, Ferritin, CRPand D-dimers were associated with death (35.75% vs. 2.61%), (24.72% vs. 9.9%), (22.7%vs. 7.8%), and (21% vs. 0%), respectively. Hydroxychloroquine treatment did not associatewith a better prognosis (25.92% vs. 14.23%). Abdominal pain, anorexia, diarrhea, nausea,and vomiting did not have any effect on the outcome. Elevated liver enzymes associatedwith poor outcome. There was more mortality in patients with cardiac diseases (25.67%vs. 14.33). Immunocompromised patients had a higher mortality rate (40% vs. 15.31%).Cough and fever were the top symptoms in our patients, but they were unrelated to theoutcome. As for treatment, patients receiving glucocorticoid displayed higher mortality(39.1% vs. 11.8%). Also, patients with shortness of breath (21.6 vs. 7.3%), those undergoingIntubation (66.6% vs. 14.5%), and mechanical ventilation (70.1% vs. 5.1%) had a highmortality rate. Conclusion: Overall, elevated liver enzymes, ferritin, CRP, and D-dimers arerobust markers of poor prognosis. The African Americans in our study displayed the highestmortality as they consisted of an older population when compared to the Hispanic group.GI symptoms did not correlate with outcome, however, they are likely important to followas the virus persists within the GI system, even after clearing from the respiratory system.

Clinical Characteristics, Gastrointestinal Manifestations And Outcomes Of Covid-19 Patients Among Minorities In The Usa

Background: It Is Well Known That Minorities Have Lower Access To Healthcare And At The Same Time Are Widely Affected By Many Comorbidities. This Predisposes Them To Worse Outcomes Compared To Others In The Current Pandemic. We Aimed To Study The Gastrointestinal (Gi) Symptoms, Comorbidities, And Clinical That Associate Covid-19 Outcomes In These Populations. Methods: We Analyzed Prospective And Retrospective Data From Sars-Cov-2 Positive Hospitalized Patients (N=5,932) From 9 Hospitals Including New York (3 Hospitals), Indiana, Rhode Island, District Of Columbia, Georgia, Michigan, And Maryland Between March And September 2020. Demographics, Comorbidities, Clinical Symptoms, And Median Laboratory Values Were Collected. The Primary Outcome Was The Rate Of In-Hospital Death. Secondary Outcomes Included Frequency And Duration Of Invasive Mechanical Ventilation, Frequency Of Treatment, And Liver Function Following Admission. Statistical Analysis Of Symptoms, Comorbidities, And Lethality Was Performed By Using Spss. Results: There Were 3713 With (62.7%) African Americans (Aa), 294 (5%) Hispanics, 1,418 (23.9%) Whites, 94 (1.5%) Asian, And 187 (3.2%) Others, 64 (1.1%) Decline, 150 (2.5%) Unknown. From 5,631 Known Ethnicity, The Average Age For Alive And Dead Was, 58 And 68 For Aa, 58 And 77 For Whites, 44 And 61 For Hispanic, And 51 And 63 Years For Asians. Males Were 47%, 41%, 47%, And 43% Among Aas, Hispanics, Whites, And Asians, Respectively. Lethality Rates Were 14.3%, 6.4%, 15.6%, Among Aas, Hispanics, And Whites, Respectively. In Chi-Squared Analysis, An Association With Lethality Was Found For Elevated Bun 14 (21.10%), Creatinine 14 (21.10%), Ferritin, Crp 304 (16.20%), D-Dimers 267 (18.00%), Ast 264 (21.10%), Prc, Troponin, Low Hemoglobin, Coronary Artery Disease, Cancer, Cardiac Disease, Hypertension (18.8%), Copd, Diabetes 281(17.20%), Diarrhea14 (21.10%), Fatigue 14 (21.10%). Use Of Glucocorticoid, Intubation, Mechanical Ventilation, Respiratory Failure, Shortness Of Breath Correlated With Death In A Significant Manner. Male Gender 311 (18.00%) And White And African Races Have A Higher Rate Of Death. These Symptoms And Commodities Were Seen Across The Board In All Races, However, Diarrhea Was Among The Most Common Gi Symptom In African Americans 50 (21.90%). Conclusion: Our Study Is Among The Largest Minority Covid-19 With Gi Manifestation That Shows Diarrhea And Elevated Liver Enzyme Ast Is Associated With Death. High Lethality Rate In African Americans In Comparison With Hispanics Is Likely Related To High Frequencies Of Comorbidities Such As Cardiovascular (Hypertension), And Diabetes. Prospective Investigations Will Likely Help A Better Characterization Of Minority Covid-19 Patients And A Better Understanding Of Factors Underlying The Observed Disparities

A Strategic City-Based Framework for Effectively and Efficiently Educating Students with Disabilities

Charter schools' autonomy and flexibility provides them with the opportunity to find ways to close the performance gap between students with and without disabilities, but deep-seated, systemic challenges often cause individual charters to struggle to do so on their own. For cities with an established charter sector, a city-wide, collaborative strategy involving all stakeholders to overcome these systemic challenges is proposed. By working together, charter schools can fulfill their potential with regard to educating students with disabilities. In the wake of the COVID-19 pandemic, identifying effective strategies to accelerate learning for students with disabilities and optimize the flexibility extended to charter schools is essential. This brief introduces critical components of a strategic, city-based framework, along with details regarding how this multi-pronged approach can drive systemic and sustainable change that will lead to better access and outcomes for students with disabilities. Each component has value independently, but when combined in a coherent manner so that each augments the others, the framework has the potential to ensure that students with disabilities have access to a robust continuum of educational opportunities in districts that have widespread public school choice and, in particular, charter schools. If individual charter schools, regional government officials, authorizers, and funders work together to create a new system that spreads the responsibility, incentivizes schools to support students with disabilities, and nurtures talent to support these goals, charter schools can be agents of change for closing the gap between students with disabilities and the general education population. [This paper is the result of a collaboration with Pathway 2 Tomorrow: Local Visions for America's Future (P2T).]

Case Study: How Gallaudet University's Office of Sponsored Programs and Research Services Implemented Their Business Continuity Plan during COVID-19

This case study describes the plans and innovations that contributed to the successful transition from traditional, in-person working to working virtually at Gallaudet University during the COVID-19 pandemic. On March 13, 2020, Gallaudet closed its campus to non-essential employees and transitioned to remote work due to the global coronavirus pandemic. Gallaudet University, a small, primarily undergraduate institution (PUI), is the world's only university in which all programs and services are specifically designed to accommodate deaf, hard of hearing, and deafblind students. Based on a master's level course paper on business continuity plans (BCP) written by an Office of Sponsored Programs and Research Services (OSPRS) employee nine-years earlier, the OSPRS implemented a business continuity plan to ensure that office operations would continue in the face of this interruption in service. If an emergency occurred and grants were due, what steps would be necessary to meet proposal deadlines? How would the OSPRS continue to be responsive to faculty and research staff and facilitate the proposal development process during an emergency? How would the office communicate during an emergency with deaf and hearing individuals and provide equal access? Answering these questions in 2011 created the innovations needed for Gallaudet University's OSPRS to successfully navigate the pandemic.