Impact of Race and Socioeconomic Status on Outcomes in Patients Hospitalized with COVID-19

BackgroundThe impact of race and socioeconomic status on clinical outcomes has not been quantified in patients hospitalized with coronavirus disease 2019 (COVID-19).ObjectiveTo evaluate the association between patient sociodemographics and neighborhood disadvantage with frequencies of death, invasive mechanical ventilation (IMV), and intensive care unit (ICU) admission in patients hospitalized with COVID-19.DesignRetrospective cohort study.SettingFour hospitals in an integrated health system serving southeast Michigan.ParticipantsAdult patients admitted to the hospital with a COVID-19 diagnosis confirmed by polymerase chain reaction.Main MeasuresPatient sociodemographics, comorbidities, and clinical outcomes were collected. Neighborhood socioeconomic variables were obtained at the census tract level from the 2018 American Community Survey. Relationships between neighborhood median income and clinical outcomes were evaluated using multivariate logistic regression models, controlling for patient age, sex, race, Charlson Comorbidity Index, obesity, smoking status, and living environment.Key ResultsBlack patients lived in significantly poorer neighborhoods than White patients (median income: $34,758 (24,531–56,095) vs. $63,317 (49,850–85,776), p < 0.001) and were more likely to have Medicaid insurance (19.4% vs. 11.2%, p < 0.001). Patients from neighborhoods with lower median income were significantly more likely to require IMV (lowest quartile: 25.4%, highest quartile: 16.0%, p < 0.001) and ICU admission (35.2%, 19.9%, p < 0.001). After adjusting for age, sex, race, and comorbidities, higher neighborhood income ($10,000 increase) remained a significant negative predictor for IMV (OR: 0.95 (95% CI 0.91, 0.99), p = 0.02) and ICU admission (OR: 0.92 (95% CI 0.89, 0.96), p < 0.001).ConclusionsNeighborhood disadvantage, which is closely associated with race, is a predictor of poor clinical outcomes in COVID-19. Measures of neighborhood disadvantage should be used to inform policies that aim to reduce COVID-19 disparities in the Black community.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06527-1.KEY WORDS: COVID-19, disparities, disadvantage, socioeconomic status, race     

Analysis of overall survival in patients with nonmetastatic castration-resistant prostate cancer treated with vaccine, nilutamide, and combination therapy

PURPOSE: We reported previously the first randomized study of any kind in patients with nonmetastatic, castrate-resistant prostate cancer. The study employed vaccine, the hormone nilutamide, and the combined therapy (crossover for each arm) with an endpoint of time to progression. We now report survival analyses at 6.5 years from the initiation of therapy with a median potential follow-up of 4.4 years. EXPERIMENTAL DESIGN: Forty-two patients were randomized to receive either a poxvirus-based prostate-specific antigen (PSA) vaccine or nilutamide. Patients in either arm who developed increasing PSA without radiographic evidence of metastasis could cross over to receive the combined therapies. RESULTS: Median survival among all patients was 4.4 years from date of enrollment. Median survival exhibited a trend toward improvement for patients initially randomized to the vaccine arm (median, 5.1 versus 3.4 years; P = 0.13). Starting from the on-study date, the retrospectively determined subset of 12 patients who initially received vaccine and then later received nilutamide suggested improved survival compared with the 8 patients who began with nilutamide and subsequently were treated with vaccine (median, 6.2 versus 3.7 years; P = 0.045). A subgroup analysis of patients randomized to the vaccine arm versus the nilutamide arm showed substantial improvements in survival if at baseline patients had a Gleason score <7 (P = 0.033) and PSA <20 ng/dL (P = 0.013) or who had prior radiation therapy (P = 0.018). CONCLUSIONS: These data indicate that patients with nonmetastatic castration-resistant prostate cancer (D0.5) who receive vaccine before second-line hormone therapy may potentially result in improved survival compared with patients who received hormone therapy and then vaccine. These data also suggest that patients with more indolent disease may derive greater clinical benefit from vaccine alone or vaccine before second-line hormone therapy compared with hormone therapy alone or hormone therapy followed by vaccine. These findings have potential implications for both the design and endpoint analysis of larger vaccine combination therapy trials.     

Methicillin-resistant Staphylococcus aureus and multidrug resistant tuberculosis: Part 1

The first of these articles reviews the epidemiology of MRSA and its clinical importance in a healthcare setting. The methods of controlling the spread of hospital acquired MRSA are discussed with an emphasis on the role of screening staff for MRSA. Relevant papers for the review were identified by a systematic literature search on Medline. The prevalence of MRSA is increasing in the United Kingdom, as is the prevalence of 'epidemic' MRSA strains. Several countries have recently reported cases of Staphylococcus aureus with intermediate-level resistance to vancomycin. The key measures to minimizing hospital-acquired MRSA are stringent infection control programmes and strict antibiotic policies. Staff screening should only be undertaken after a detailed risk assessment of the local situation has been made by the occupational health and infection control teams. Priority should be given to high-risk areas of a hospital where MRSA is endemic.     

Methicillin-resistant Staphylococcus aureus and multidrug resistant tuberculosis: Part 2

Drug resistant tuberculosis has been recognized since chemotherapy first became available. However, drug resistance has increased in many countries, and recently strains resistant to both rifampicin and isoniazid (multidrug resistant tuberculosis) have emerged. This review discusses the epidemiology of multidrug resistant tuberculosis (MDRTB), and the control of MDRTB in healthcare facilities. Relevant papers for this review were identified by a systematic literature search on Medline. MDRTB is already established world-wide, and although the overall problem of resistance remains low in the UK, it is of significant clinical importance due to its high case-fatality, higher transmission risk, and complex treatment. The key elements of MDRTB control are prompt recognition, confirmation and treatment of cases, and the institution of strict infection control procedures to reduce the airborne spread of infection from infectious patients to others. This review emphasizes the importance of a multidisciplinary approach to management, with liaison between tuberculosis physicians, the microbiology department, infection control team, consultant in communicable disease, and occupational health.     

Prevalence of cryptosporidiosis in Dammam and Alkhobar, Saudi Arabia

This report presents results from a 6-month study over the period 16 November 1986 to 15 May 1987 which was designed to investigate the prevalence of cryptosporidiosis in Dammam and Alkhobar, Saudi Arabia. A total of 209 stool specimens from children and 112 from adults with diarrhoea were examined. Only two (1%) of the children, both aged 2 years, were positive for Cryptosporidium spp. Giardia lamblia was found in 13 (4%) cases and was found to be the most common protozoan parasite, whereas Salmonella spp. was seen in 19 (6%) cases. Stool specimens were examined for rotavirus from children under 2 years of age; 31 (41%) of the specimens were positive.     

Serum enzymes in head and neck cancer. II. Aliesterase

Serum aliesterase levels have been estimated in 38 patients with head and neck cancer. The mean value was significantly lower than in controls. The decrease in activity was greater in patients with ulcerative growths and it progressed with advancement in the stage of cancer. With radiotherapy, a progressive and significant increase in serum aliesterase activity was observed. In patients with non-malignant growths the activity was comparable with that in controls.     

Remifentanil and propofol sedation for retrobulbar nerve block

We studied remifentanil and propofol for analgesia and sedation during the placement of an ophthalmic block. Eighty ASA I or II patients undergoing elective cataract surgery under a retrobulbar block in a rural camp setting were included in the study. Patients were randomly divided into four groups and received different drug combinations as follows: Group I--remifentanil 1 microg/kg, Group II--remifentanil 0.5 microg/kg and propofol 0.5 mg/kg, Group III--remifentanil 1 microg/kg with propofol 0.5 mg/kg and Group IV--saline 0.1 ml/kg. Patients were observed for degree of movement, sedation, pain, recall and respiratory depression. No patient in the study groups reported pain or displayed movement whereas most of the patients in the control group had significant pain during the placement of the block. Also, seven (35%) patients in the control group showed significant movement which may have led to failure of block in two patients and retrobulbar haemorrhage in one patient. Incidence of significant respiratory depression was maximum in Group III patients (60%), followed by Group I (20%) and least in Group II (5%). All patients in the study groups remained cooperative and obeyed commands except four patients in group III (OAA/S-4). Postoperatively, other than the control group, recall was maximum in Group I (55%) and least in Group II (5%). Hence, a combination of remifentanil 0.5 microg/kg with propofol 0.5 mg/kg as a bolus was considered to provide excellent relief of pain and anxiety with least adverse effects for the placement of ophthalmic blocks.