Wyckoff Heights Medical Center

BACKGROUND: New psychoactive substances constitute a growing and dynamic class of abused drugs in the United States. On July 12, 2016, a synthetic cannabinoid caused mass intoxication of 33 persons in one New York City neighborhood, in an event described in the popular press as a "zombie" outbreak because of the appearance of the intoxicated persons. METHODS: We obtained and tested serum, whole blood, and urine samples from 8 patients among the 18 who were transported to local hospitals; we also tested a sample of the herbal "incense" product "AK-47 24 Karat Gold," which was implicated in the outbreak. Samples were analyzed by means of liquid chromatography-quadrupole time-of-flight mass spectrometry. RESULTS: The synthetic cannabinoid methyl 2-(1-(4-fluorobenzyl)-1H-indazole-3-carboxamido)-3-methylbutanoate (AMB-FUBINACA, also known as MMB-FUBINACA or FUB-AMB) was identified in AK-47 24 Karat Gold at a mean (±SD) concentration of 16.0±3.9 mg per gram. The de-esterified acid metabolite was found in the serum or whole blood of all eight patients, with concentrations ranging from 77 to 636 ng per milliliter. CONCLUSIONS: The potency of the synthetic cannabinoid identified in these analyses is consistent with strong depressant effects that account for the "zombielike" behavior reported in this mass intoxication. AMB-FUBINACA is an example of the emerging class of "ultrapotent" synthetic cannabinoids and poses a public health concern. Collaboration among clinical laboratory staff, health professionals, and law enforcement agencies facilitated the timely identification of the compound and allowed health authorities to take appropriate action.

To improve sexual health, even in this charged political moment, necessitates going beyond biomedical approaches, and requires meaningfully addressing sexual rights and sexual pleasure. A world where positive intersections between sexual health, sexual rights and sexual pleasure are reinforced in law, in programming and in advocacy, can strengthen health, wellbeing and the lived experience of people everywhere. This requires a clear understanding of what interconnection of these concepts means in practice, as well as conceptual, personal and systemic approaches that fully recognise and address the harms inflicted on people's lives when these interactions are not fully taken into account. Bridging the conceptual and the pragmatic, this paper reviews current definitions, the influences and intersections of these concepts, and suggests where comprehensive attention can lead to stronger policy and programming through informed training and advocacy.

BACKGROUND AND OBJECTIVES: Discrimination toward the lesbian, gay, bisexual and transgender (LGBT) population has raised concerns about the type of long-term services and supports (LTSS) that will be available to them as they age. To understand the unique needs of aging LGBT populations, we sought to synthesize and critique the evidence related to LTSS providers and LGBT individuals' perspectives of LGBT issues in LTSS in the United States. RESEARCH DESIGN AND METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, a systematic review of the literature was conducted. The Crowe Critical Appraisal Tool was used to appraise the quality of the included studies. RESULTS: Nineteen studies met inclusion criteria. Seven studies that examined the perspectives of LTSS providers identified two themes, including that they lack knowledge and training on LGBT health issues and generally report negative attitudes toward same-sex relations among older adults. In addition, 12 studies that examined the perspectives of LGBT individuals found that they (i) are concerned about LTSS planning, (ii) fear discrimination from providers in LTSS, and (iii) identify several strategies for improving care of LGBT older adults receiving LTSS. DISCUSSION AND IMPLICATIONS: This systematic review highlights the importance for LTSS providers to receive training in LGBT health and be reflective of potential biases toward the LGBT population. LGBT individuals identified concerns related to LTSS planning and fear of discrimination from LTSS providers. LGBT individuals also identified a need for increased training of providers to improve the care of LGBT older adults in LTSS.

The globalization of medical research and global health's increasing popularity worldwide have resulted in greater geographic, ethnic, and socioeconomic diversity of studies published in the scientific literature. Yet the geographic distribution, authorship representation, and subject trends among Low-/Low-Middle-Income Country (LIC/LMIC)-based scientific publications remain largely unknown. This analysis assesses these gaps in knowledge. We performed a comprehensive bibliometric analysis of all scientific articles published between January 2014 and June 2016 in the four most prominent general medicine and five most prominent general global health journals based on impact factor. The African region, containing 24% of the global LIC/LMIC population, accounted for 49.9% of all publications. Corresponding authors with either exclusive or joint appointment to a LIC/LMIC institution were present in 26.2% of all included articles. Over one-quarter (28.8%) of all publications did not list a local author. Nearly two-thirds (62.1%) of articles published in global health journals and roughly half (52.4%) in general medicine journals involved infectious diseases. Non-HIV infectious disease studies were by far the most frequent subject areas across all journals. The trends identified in this study may help to inform the evolution and prioritization of future research efforts, thereby allowing global health to remain truly global.

Structural chromosome mosaicism is rare. We report a case of prenatal mosaicism for a deletion of chromosome 10(q23). To our knowledge, there are only three reports of prenatally diagnosed cases of del(10)(q23). Two of these cases were due to an inherited fragile site. In the present case amniocentesis revealed 46,XY,del(10)(q23)[9]/46,XY[45]. Follow-up chromosome analysis of peripheral blood and placental tissue from a phenotypically normal liveborn male revealed the del(10)(q23) in only 3/100 blood cells grown in low-folate medium. It appears that prenatally diagnosed deleted (10q) mosaicism represents culture artifact and is not clinically significant.

Abstract Context Conventional treatment of hypoparathyroidism is associated with decreased renal function and increased bone mineral density (BMD). Objective To evaluate the effects of 8 years of recombinant human parathyroid hormone (1-84) [rhPTH(1-84)] therapy on key biochemical and densitometric indices. Design Prospective open-label trial. Setting Tertiary medical center. Participants Twenty-four subjects with hypoparathyroidism. Intervention Treatment with rhPTH(1-84) for 8 years. Main Outcome Measures Supplemental calcium and vitamin D requirements, serum calcium and phosphorus levels, calcium-phosphate product, urinary calcium excretion, estimated glomerular filtration rate (eGFR) and BMD. Results PTH therapy was associated with progressive reduction in supplemental calcium (57%; P < 0.01) and active vitamin D (76%; P < 0.001) requirements over 8 years. Serum calcium concentration was stable; urinary calcium excretion declined 38% (P < 0.01). eGFR remained stable and was related to baseline eGFR and serum calcium levels. Calcium-phosphate product was below the recommended limit; serum phosphorus remained within normal range. Lumbar spine and total hip BMD increased, peaking at 4 (mean ± SE, 4.6% ± 1.5%; P = 0.01) and 8 years (2.6% ± 1.1%; P = 0.02), whereas femoral neck BMD did not change and one-third radius BMD decreased (mean ± SE, −3.5% ± 1.1%; P = 0.001). BMD at all sites was higher throughout the 8 years than in the age- and sex-matched reference population. Hypercalcemia and hypocalcemia were uncommon. Conclusion rhPTH(1-84) is a safe and effective treatment for hypoparathyroidism for 8 years. Long-term reductions in supplemental requirements and biochemical improvements with stable renal function are maintained.

OBJECTIVES: To compare pregnancy outcomes for teenagers with those for older gravidas. METHODS: A retrospective case control study was undertaken to compare teenagers who delivered between January 1996 and October 1999 at a public urban hospital with a group of older gravidas. RESULTS: Young pregnant teenagers were more likely to be nulliparous. They weighed less and gained less in pregnancy. More teen pregnancies occurred among Hispanics than other ethnic groups. The younger the teenager, the more likely for her infant to be of low or very low birth weight or growth restricted. There were fewer postmature deliveries, macrosomic fetuses and cesarean deliveries in young gravidas. Perinatal mortality was unaffected by maternal age. CONCLUSIONS: This investigation demonstrates that, while pregnancy outcomes in teenagers have improved in recent years relative to historical patterns, teenagers face continuing problems requiring special attention by care givers.

OBJECTIVE: To determine the prevalence of iron deficiency and iron deficiency anemia in children aged 1 to 3 years in an urban population. DESIGN: Venous blood was measured for levels of hemoglobin, ferritin, free erythrocyte protoporphyrin, and lead in children seen for well-child visits. Children with histories of chronic illness, prematurity, blood dyscrasias, and acute illness were excluded. SETTING: The private practice offices of 4 pediatricians in the New York City area. PATIENTS: A consecutive sample of 504 children aged 1 to 3 years was included. RESULTS: More than one third (35%) of the children demonstrated evidence of iron insufficiency; 7% were iron deficient without anemia, and 10% had iron deficiency anemia. CONCLUSION: Because the association of iron deficiency anemia with mental and psychomotor impairment during the first 2 years of life no longer seems to be in doubt, the high prevalence of iron deficiency anemia found in the 1- to 2-year-old children in this study is disturbing. This suggests the need for greater efforts at the prevention of iron deficiency during the second year of life.

UNLABELLED: Infection by hepatitis C virus (HCV) usually results into chronic hepatitis that can ultimately lead to cirrhosis and hepatocellular carcinoma. Type 1 interferons (IFN-alpha/beta) constitute the primary cellular defense against viral infection including HCV. IFN binding to their receptors activates associated Jak1 and Tyk2 kinases, which ultimately leads to phosphorylation and assembly of a signal transducer and activator of transcription protein (STAT)1-STAT2-interferon regulatory factor (IRF)9 trimetric complex called interferon-stimulated gene factor 3 that translocates into the nucleus and binds to the interferon- stimulated response elements (ISRE), leading to transcriptional induction of several antiviral genes, including double-stranded RNA-activated protein kinase (PKR), 2',5'- oligoadenylate synthetase (OAS), and myxovirus resistance protein A (MxA). Understanding the mechanisms of how the virus evades this cellular innate defense and establishes a chronic infection is the key for the development of better therapeutics against HCV infection. Here, we demonstrate that p53 could have a crucial role in the cellular innate defense against HCV. We observed significantly higher levels of HCV RNA replication and viral protein expression in the Huh7 cells when their p53 expressions were knocked down. Moreover, IFN treatment was less effective in inhibiting the HCV RNA replication in the p53-knocked-down (p53kd) Huh7 cells. In fact, the activation of the ISRE and the induction of ISGs were significantly attenuated in the p53kd Huh7 cells and p53 was found to directly interact with IRF9. CONCLUSION: These observations underscore the potential contributions of the tumor suppressor p53 in cellular antiviral immunity against HCV with possible therapeutic implications.

Prostate cancer is the most frequent malignancy and the second leading cause of cancer deaths among males in the Western world. The clinical course of the disease is highly complex, and genetic factors underlying tumorigenesis are poorly understood. The challenge that lies ahead is to identify the important gene(s) that causes adenocarcinoma of the prostate. Chromosomal findings by cytogenetic and molecular methods, including Southern blotting, microsatellite analysis, fluorescence in situ hybridization, and comparative genomic hybridization, revealed a high frequency of chromosomal aberrations of heterogeneous nature, including: -1, +1, -1q, +4, -6q, -7, +7, -8, -8p, -8q, +i(8q), -9, -9p, -10, +10, +11, -12, -13q, -16, -16q, +16, -17, +17, +17q, -18, +18, -18q, +19p, +20q, +X, -Xq, -Y, and +Y. Specific chromosomal regions of alterations were 1q24-25, 2cen-q31, 5cen-q23.3, 6q14-23.2, 7q22-q31, 8p12-21, 8p22, 8q24-qter, 10q22.1, 10q23-25, 11p11.2, 16q24, 17p13.1, 18q12.2, and Xq11-12. Recently, a predisposing gene for early onset has been localized on 1q42.2-43. The losses of heterozygosity at specific chromosomal loci from chromosomes 5q, 6q, 7q, 8p, 8q, 10q, 13q, 16q, 17p, 17q, and 18q are generally correlated with poor prognosis in advanced tumor stage. In addition, an abnormal function of known tumor suppressor genes from these regions have been observed in prostate cancer. Although, the amplification of the androgen receptor gene at Xq11-13 and HER-2/neu gene at 17q11.2-q12 are novel findings, no single gene has been implicated in harboring prostate cancer. Frequent inactivation of PTEN/MMAC1 tumor suppressor gene at 10q23, MXI-1 at 10q25, KAI-1 at 11p11.2, Rb at 13q14.2, and p53 at 17p13.1 and deregulation of c-myc oncogene at 8q24 have recently been the subject of intense scrutiny and debate.

CONTEXT: Calcium and vitamin D treatment does not improve reduced quality of life (QOL) in hypoparathyroidism. Recombinant human (rh) PTH(1-84) therapy improves QOL metrics for up to 5 years. Data on QOL beyond this time point are not available. OBJECTIVES: To evaluate the effects of 8 years of rhPTH(1-84) therapy on QOL and factors associated with long-term benefit. DESIGN: Prospective, open-label trial. SETTING: Referral center. PATIENTS: Twenty patients with hypoparathyoidism. MAIN OUTCOME MEASURES: RAND 36-Item Short Form Health Survey (SF-36). RESULTS: rhPTH therapy led to substantial improvement in five of the eight SF-36 domains [vitality, social functioning (SF), mental health (MH), bodily pain (BP) and general health] and three of these domains (SF, MH, BP) were no longer lower than the reference population. The improvement in the mental component summary (MCS) score was sustained through 8 years, while the physical component summary (PCS) score improved through 6 years. A lower baseline QOL score was associated with greater improvement. A threshold value <238 (MCS) and <245 (PCS) predicted long-term improvement in 90% and 100% of the cohort, respectively. In patients whose calcium supplementation was reduced, MCS and PCS scores improved more than those whose supplementation did not decline to the same extent. Improvement in PCS was greater in patients whose calcitriol dosage was reduced and duration of disease was shorter. CONCLUSIONS: rhPTH(1-84) improves long-term well-being in hypoparathyroidism. The improvements are most prominent in those with impaired SF-36 at baseline and those whose requirements for conventional therapy decreased substantially.

As of September 6, 2020, there were nearly 27 million confirmed cases of coronavirus disease 2019 (COVID-19) worldwide, with >870,000 deaths. From mid-March through May 2020, New York City was the epicenter of the United States outbreak. As the pandemic continued, information regarding the effects of COVID-19 on patients on dialysis became available.1,2 Generally, patients on dialysis have high rates of hospitalizations and mortality for cardiovascular and infectious causes,3 with infections the second most common cause of death.4 In the setting of COVID-19, patients on dialysis have specific risk factors associated with this highly contagious pathogen: older age3 and high prevalence rates of diabetes mellitus and hypertension, all of which are associated with worse outcomes in COVID-19.1,2,5 Studies thus far have not described the natural history, spectrum of disease, or effects of COVID-19 on patients on dialysis. In this article, we report the experience of a small dialysis organization in the New York City and Long Island region from March 8, 2020 to April 20, 2020. A surveillance program identified patients on dialysis with suspected or confirmed COVID-19 by screening at every dialysis encounter, providing the opportunity to explore the challenges related to social determinants of health, particularly race or ethnicity and immigration status. Methods Atlantic Dialysis Management Services, LLC (ADMS), a regional small dialysis organization operating 13 facilities in New York City and Long Island, initiated a prospective Centers for Disease Control and Prevention–guided program to screen patients on dialysis for signs and symptoms of COVID-19 as well as ascertain known unprotected exposure (no mask on at least one person) to a person with symptoms or confirmed COVID-19 diagnosis. Positively screened patients on dialysis were referred for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing, hospitalization, or both and were considered persons under investigation (PUIs). PUIs were followed for symptom changes, hospitalization, death, and results of COVID-19 testing (Supplemental Figure 1). Asymptomatic PUIs or those negative for COVID-19 were considered COVID-19–negative. PUIs who tested positive, had signs and symptoms consistent with COVID-19, or both were considered COVID-19–positive or COVID-19–symptomatic patients. We obtained demographic information from the facilities’ electronic health records. Patients on dialysis without Social Security numbers were considered undocumented residents.6 Statistical analysis focused on the PUI cohort. Chi-squared tests compared demographic characteristics between COVID-19–positive/symptomatic and COVID-19–negative groups. Focusing on the COVID-19–positive/symptomatic cohort, we explored how demographic characteristics and comorbidities were associated with hospitalization and mortality as outcomes (using bivariate Firth penalized logistic regressions because of the limited number of patients). We used Stata 14 (StataCorp 2014) for all analyses. Results and Discussion Among our study population of 2178 patients on dialysis, we found a 14% prevalence of COVID-19–positive/symptomatic patients, much higher than the 2.6% prevalence in the general New York City population.5 There were 408 PUIs; 306 PUIs (75%) were COVID-19-positive/symptomatic, and 244 of the latter (79.7%) had confirmed positive COVID-19 tests, an incidence of 112 per 1000 (Supplemental Figure 1). Given overall rates of COVID-19 of 25 per 1000 for New York City and 28 per 1000 for the New York City borough of Queens,5 it is apparent that New York City patients on dialysis were at higher risk of community exposure to COVID-19. The most common signs and symptoms of COVID-19 in the study population were fever (44%), cough (28%), and weakness or fatigue (20%), similar to those found in a recent study of ESKD admissions at a New York City medical center.1 Compared with COVID-19–negative patients, COVID-19–positive/symptomatic patients had considerably higher odds of death and hospitalization and marginally higher odds of emergency department visits (Supplemental Table 1). Demographic characteristics and specific residence were similar for both groups (Supplemental Table 2). COVID-19–positive/symptomatic patients were more likely to be men and Black or Hispanic; their average age was 64 years, and their time on dialysis was longer compared with the total ADMS population of patients on dialysis (Supplemental Table 3). Of the 306 COVID-19–positive/symptomatic patients, 135 (44%) resided in Queens, comprising 15% of the 880 ADMS patients on dialysis in Queens (Supplemental Table 3). Of the 104 ADMS patients on dialysis in Manhattan, 24 (23%) were COVID-19 positive/symptomatic (a higher rate than in Queens and other locations), but more than half the patients on dialysis in the Manhattan facilities were from nursing homes. Of the cohort of COVID-19–positive/symptomatic patients, 178 (58%) were hospitalized, 8% of the total ADMS population (Table 1). Patients residing in Queens had significantly increased odds of hospitalization (odds ratio [OR], 2.39; 95% confidence interval [95% CI], 1.01 to 5.69) (Table 2). The increased odds likely reflects the high population density of Queens.7 Table 1. - Demographic characteristics and comorbidities of the total ESKD population, of the total COVID-19 (those positive for SARS-CoV-2 RNA and those presumed to be positive on the basis of case presentation and symptoms) cohort, and by outcome COVID-19 (+/S) Patients, n=306 Hospitalized COVID-19 (+/S) Patients, n=178 COVID-19 (−) Patients, n=102 Died COVID-19 (+/S) Patients, n=85 Total ADMS Patients, n=2178 Age, yr, n (%) 18–44 30 (10) 18 (10) 13 (13) 3 (4) 221 (10) 45–54 44 (14) 28 (16) 19 (19) 4 (5) 323 (15) 55–64 73 (24) 39 (22) 27 (26) 17 (20) 569 (26) 65–74 87 (28) 46 (26) 23 (23) 26 (31) 559 (26) Over 75 72 (24) 47 (26) 21 (21) 35 (41) 508 (23) Average age, yr 64±13.5 64±12.6 61±14.8 70±11.9 63±14.0 ESKD vintage, yr 4.5±4.0 4.8±4.4 3.7±3.1 5.5±4.4 3.8±6.0 Men, n (%) 192 (63) 106 (60) 61 (60) 57 (67) 1299 (60) Race, n (%) White 31 (10) 23 (13) 11 (11) 8 (9) 234 (11) Black 117 (38) 67 (38) 45 (44) 33 (39) 749 (34) Asian 39 (13) 20 (11) 12 (12) 13 (15) 221 (10) Hispanic 113 (37) 67 (38) 29 (28) 28 (33) 537 (25) Comorbid conditions, n (%) Diabetes 110 (36) 87 (49) 43 (42) 43 (51) 1418 (65) Hypertension 115 (38) 86 (48) 43 (42) 38 (45) 1309 (60) CHF 30 (10) 25 (14) 13 (13) 18 (21) 207 (10) CAD 15 (5) 24 (13) 3 (3) 15 (18) 293 (13) Location Brooklyn 92 (30) 52 (29) 33 (3) 28 (33) 634 (29) Queens 135 (44) 84 (47) 51 (50) 34 (40) 880 (40) Bronx 30 (10) 17 (10) 9 (9) 10 (12) 293 (13) Nassau and Suffolk Counties 24 (8) 15 (8) 7 (7) 8 (9) 201 (9) Manhattan 24 (8) 10 (6) 2 (2) 4 (5) 104 (5) Treatment modality, n (%) Peritoneal dialysis 2 (0.6) 2 (1) 2 (2) 1 (1) Home hemodialysis 1 (0.3) 1 (0.6) Death, n (%) 85 (28) 48 (25) 0 Hospitalized/died includes all patients in the PUI group who were hospitalized or died, and total ADMS indicates prevalent patients on dialysis at all facilities. COVID-19 (+/S), all individuals tested positive for SARS-CoV-2 RNA and those presumed to be positive on the basis of case presentation and symptoms. CHF, congestive heart failure; CAD, coronary artery disease. Table 2. - Risk factors for hospitalization and death in the COVID-19 (those positive for SARS-CoV-2 RNA and those presumed to be positive on the basis of case presentation and symptoms) cohort Hospitalization Death OR (95% CI) P Value OR (95% CI) P Value Borough/City Manhattan 1 1 Queens 2.39 (1.01 to 5.69) 0.05 1.64 (0.55 to 4.86) 0.37 Brooklyn 1.79 (0.73 to 4.38) 0.28 2.01 (0.66 to 6.12) 0.22 Bronx 1.79 (0.62 to 5.19) 0.20 2.33 (0.66 to 8.25) 0.19 Long Island 1.64 (0.52 to 5.15) 0.39 1.79 (0.46 to 7.03) 0.40 Sex Women 1 1 Men 0.72 (0.45 to 1.16) 0.18 1.29 (0.76 to 2.17) 0.34 Race/ethnicity White 1 1 Black 0.47 (0.20 to 1.13) 0.91 1.08 (0.45 to 2.61) 0.86 Hispanic 0.51 (0.21 to 1.22) 0.13 0.95 (0.39 to 2.32) 0.92 Asian 0.38 (0.14 to 1.03) 0.06 1.40 (0.51 to 3.91) 0.51 Multiracial or other 0.36 (0.03 to 3.97) 0.41 2.76 (0.25 to 30.33) 0.40 Social Security number Yes 1 1 No 0.96 (0.54 to 1.68) 0.89 2.34 (1.31 to 4.18) 0.004a Age, yr 18–44 1 1 45–54 1.17 (0.46 to 2.99) 0.75 0.87 (0.20 to 3.82) 0.86 55–64 0.77 (0.33 to 1.81) 0.55 2.43 (0.71 to 8.37) 0.16 65–74 0.76 (0.33 to 1.74) 0.51 3.38 (1.02 to 11.26) 0.05a 75 or older 1.26 (0.53 to 2.99) 0.60 7.44 (2.23 to 24.78) 0.001a ESKD vintage, yr 0.97 (0.92 to 1.03) 0.31 1.1 (1.01 to 1.14) 0.01a Diabetes No 1 1 Yes 1.27 (0.80 to 2.00) 0.31 1.26 (0.77 to 2.07) 0.36 Hypertension No 1 1 Yes 0.91 (0.58 to 1.43) 0.67 0.77 (0.47 to 1.28) 0.32 CHF No 1 1 Yes 0.79 (0.42 to 1.46) 0.45 1.78 (0.94 to 3.41) 0.08 CAD No 1 1 Yes 0.71 (0.38 to 1.32) 0.28 1.28 (0.66 to 2.49) 0.46 Results from univariate Firth penalized logistic regressions with hospitalization and death as outcomes, and demographic variables and comorbidities as explanatory variables. The nonadjusted OR and the 95% CI are indicated for each outcome. CHF, congestive heart failure; CAD, coronary artery disease.aStatistically significant. Among the COVID-19–positive/symptomatic patient cohort, 85 deaths (28%) occurred, representing 4% of the total ADMS population (Table 1). Patients who died were older (70 [SD, 11.9] years old), had a longer ESKD duration (5.5 [SD, 4.4] years), and were disproportionately men (Table 1). Mortality was associated with age >65 years and longer ESKD duration, with a 10% increase for each additional year on dialysis (Table 2). The proportion of deaths among hospitalized patients was not significantly different from that of patients who were not hospitalized (26.8% versus 28.9%, respectively; chi square =0.13; P=0.71), suggesting that at-home mortality occurred. Although minorities were less likely to be hospitalized compared with non-Hispanic Whites (Table 2), the difference was not significant. Asians had the lowest hospitalization rate. This finding, in addition to the high proportion of deaths in nonhospitalized COVID-19–positive/symptomatic patients, suggests there may be disparities in seeking acute care. Alternatively, it may represent a higher risk of sudden death in ESKD3 related to COVID-19 infection.2 Exploring the relationship between race and other demographic factors and mortality among COVID-19–positive/symptomatic patients will be an important avenue of study. Undocumented patients on dialysis had twice the odds of dying (Table 2). Immigrants, especially undocumented individuals, tend to have lower-paying jobs and thus often share households to make ends meet, which likely increased their exposure to SARS-CoV-2. Moreover, although undocumented patients on dialysis were younger (chi square =22.1; P<0.001), they also had longer duration of ESKD (Kruskal–Wallis test; P<0.01). When adding Social Security numbers to the multivariate model including ESKD duration and age, ESKD duration was no longer significant (adjusted OR, 1.06; 95% CI, 0.99 to 1.13; P=0.09). This indicates that Social Security number or immigration status and age were more significant risk factors of death than ESKD duration and that undocumented status in the COVID-19–positive/symptomatic patient population was associated with greater mortality, despite younger age. Queens is home to a large immigrant and undocumented population from diverse areas, ranging from Asia to South America.8 Being undocumented is associated with lower socioeconomic status and a lack of education and health insurance, reflecting social determinants of health associated with poorer health outcomes.6 These barriers, in addition to fear of discovery by authorities and loss of work, often compound health disparities for this population.9 It is possible that delayed acute care as well as disparities in chronic health care influenced mortality. We did not find other demographic variables to be associated significantly with mortality but observed some trends. Among COVID-19–positive/symptomatic patients, Asians were disproportionately more likely to die and have lower hospitalization rates compared with non-Hispanic whites (Tables 1 and 2). Men were less likely than women to be hospitalized (OR, 0.72; 95% CI, 0.45 to 1.16) and more likely to die (OR, 1.29; 95% CI, 0.76 to 2.17) (Table 2). Strengths of this analysis are real-time detection and disease risk mitigation. Our sample size is larger than those of previous studies and more diverse with respect to ethnicity, race, and socioeconomic status.1,2 We were also able to trace out-of-hospital deaths. Limitations of the study include electronic medical record data being subject to inaccurate entry and unavailability of details about location and cause of death. In areas with population densities that differ from those of the areas we studied, findings and outcomes may vary. In addition, limited access to SARS-CoV-2 PCR diagnostic testing in New York City at the time of the study resulted in the authors’ decision to present results as COVID-19–positive/symptomatic patients on the basis of the high pretest probability of COVID-19. This raises the possibility of misclassification bias, and known limitations of SARS-CoV-2 PCR sensitivity also increased the possibility of false-negative findings. ESKD duration is represented as total years since first dialysis treatment and does not account for nondialysis periods. Only a very small proportion of PUIs in our study used home dialysis, and results cannot be generalized to this population. In the COVID-19 pandemic, person-to-person exposure in densely populated cities has been key in explaining the devastating effects.10 Patients on dialysis receiving outpatient hemodialysis must leave their home multiple times per week, regardless of stay-at-home orders. As a result, they face increased infection risk because of exposure to others, whether on mass transportation, through shared transportation rides, or in facility waiting rooms. Population density and related socioeconomic factors may be key to understanding disease transmission among this patient population. Disclosures G. Coritsidis is a salaried director of the Broadway dialysis unit, the data of which are included in the paper as one of the 13 units. G. Coritsidis reports personal fees from Atlantic Dialysis Management Services, LLC during the conduct of the study. All remaining authors have nothing to disclose. Funding None.

Kamani et al. [1Kamani N.R. Walters M.C. Carter S. et al.Unrelated donor cord blood transplantation for children with severe sickle cell disease: results of one cohort from the phase II study from the Blood and Marrow Transplant Clinical Trials Network (BMT CTN).Biol Blood Marrow Transplant. 2012; 18: 1265-1272Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar] recently reported on the results of the cord blood recipient cohort of the Sickle Cell Unrelated Donor Transplant Trial (SCURT trial) of the Blood and Marrow Transplant Clinical Trials Network. Of the 8 children undergoing unrelated donor cord blood transplantation (UCBT) after reduced-intensity conditioning with alemtuzumab, fludarabine and melphalan, 5 had primary graft failure resulting in a 1-year event-free survival of 37.5%. We previously reported the outcome of reduced toxicity conditioning (RTC) and UCBT in pediatric recipients [2Bradley M.B. Satwani P. Baldinger L. et al.Reduced intensity allogeneic umbilical cord blood transplantation in children and adolescent recipients with malignant and non-malignant diseases.Bone Marrow Transplant. 2007; 40: 621-631Crossref PubMed Scopus (68) Google Scholar, 3Geyer M.B. Jacobson J.S. Freedman J. et al.A comparison of immune reconstitution and graft-versus-host disease following myeloablative conditioning versus reduced toxicity conditioning and umbilical cord blood transplantation in paediatric recipients.Br J Haematol. 2011; 155: 218-234Crossref PubMed Scopus (41) Google Scholar]. We report here a similar experience with that of Kamani et al. with an RTC regimen of busulfan, fludarabine, and alemtuzumab before UCBT in children with sickle cell disease (SCD). During the period of 2004 to 2010, we investigated the combination of busulfan (3.2 to 4 mg/kg/day IV divided BID, days -8 to -5), fludarabine (30 mg/m2/day IV, days -8 to -3), and alemtuzumab (2 mg/m2 day -6, 6 mg/m2 days -5,-4, and 20 mg/m2 days -3, -2; 54 mg/m2 total dose, days -6 to -2) as we have previously described [4Styczynski J. Tallamy B. Waxman I. et al.A pilot study of reduced toxicity conditioning with BU, fludarabine and alemtuzumab before the allogeneic hematopoietic SCT in children and adolescents.Bone Marrow Transplant. 2011; 46: 790-799Crossref PubMed Scopus (32) Google Scholar] as a conditioning regimen for 8 consecutive pediatric patients with high-risk SCD undergoing UCBT. Acute graft-versus-host disease (GVHD) prophylaxis consisted of mycophenolate mofetil and tacrolimus, as we have previously reported [5Bhatia M. Militano O. Jin Z. et al.An age-dependent pharmacokinetic study of intravenous and oral mycophenolate mofetil in combination with tacrolimus for GVHD prophylaxis in pediatric allogeneic stem cell transplantation recipients.Biol Blood Marrow Transplant. 2010; 16: 333-343Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar]. Median age of patients was 3.6 years (range, 1 to 10 years) with a male-to-female ratio of 7:1. Among evaluable (5 of 8) UCBT recipients, 62.5% engrafted neutrophils at median day 34 (range, 27 to 47). In addition to the 3 unrelated UCBT recipients who did not engraft neutrophils, one unrelated UCBT recipient achieved absolute neutrophil count >500/mm3 for 3 days but did not achieve >50% donor chimerism in whole blood by day +60 and was therefore classified as having primary graft failure. Of evaluable UCBT recipients, 50% engrafted donor platelets at median day 54 (range, 43 to 70). The probability of grade II to grade IV acute GVHD was 50.0%, and the probability of grade III to grade IV acute GVHD was 25.0%. One recipient developed chronic GVHD, which was limited. Two-year event-free survival and overall survival were 50% and 62.5%, respectively. Three patients with primary graft failure died from infection: one died from cytomegalovirus pneumonitis on day +84, another died of adenovirus on day +128 and one patient, who had developed primary graft failure due to cytomegalovirus, received a second allograft 1 year later for persistent aplasia and died of Candida parapsilosis. Our institution's experiences closely parallel the results reported by Kamani et al. with high incidence of graft failure after RTC and UCBT in pediatric recipients with high-risk SCD. All 3 primary graft failures were associated with viral infections. However, we previously reported no change in incidence of systemic viral and invasive fungal infections after RTC versus myeloablative conditioning before allogeneic stem cell transplantation in pediatric recipients [6Satwani P. Baldinger L. Freedman J. et al.Incidence of Viral and fungal infections following busulfan-based reduced-intensity versus myeloablative conditioning in pediatric allogeneic stem cell transplantation recipients.Biol Blood Marrow Transplant. 2009; 15: 1587-1595Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. Perhaps more immunosuppressive regimens in patients with SCD undergoing UCBT may be necessary to overcome immunologic barriers to engraftment in these patients. Additionally, double cord blood transplantation, facilitative cellular therapy, and ex vivo umbilical cord blood expansion have the potential to improve outcomes in UCBT recipients with SCD [7Bradley M.B. Cairo M.S. Cord blood immunology and stem cell transplantation.Hum Immunol. 2005; 66: 431-446Crossref PubMed Scopus (59) Google Scholar, 8Cairo M.S. Rocha V. Gluckman E. et al.Alternative allogeneic donor sources for transplantation for childhood diseases: unrelated cord blood and haploidentical family donors.Biol Blood Marrow Transplant. 2008; 14: 44-53Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar]. Alternate stem cell sources should also be considered, such as matched unrelated (currently being studied in the SCURT trial) or haploidentical donors [9Freed J. Talano J. Small T. et al.Allogeneic cellular and autologous stem cell therapy for sickle cell disease: 'whom, when and how'.Bone Marrow Transplant. 2012; 47: 1489-1498Crossref PubMed Scopus (14) Google Scholar]. We are pursuing a new pilot study to evaluate the efficacy of T cell depleted haploidentical allogeneic stem cell transplantation in patients with high risk SCD lacking human leukocyte antigen matched-sibling and 8/8 human leukocyte antigen-matched unrelated donors [9Freed J. Talano J. Small T. et al.Allogeneic cellular and autologous stem cell therapy for sickle cell disease: 'whom, when and how'.Bone Marrow Transplant. 2012; 47: 1489-1498Crossref PubMed Scopus (14) Google Scholar, 10Geyer M.B. Ricci A.M. Jacobson J.S. et al.T cell depletion utilizing CD34(+) stem cell selection and CD3(+) addback from unrelated adult donors in paediatric allogeneic stem cell transplantation recipients.Br J Haematol. 2012; 157: 205-219Crossref PubMed Scopus (28) Google Scholar]. Presented in part at the Blood and Marrow Transplant Tandem Meetings, February, 2011, Honolulu. Financial disclosure: This research was supported in part by grants from the Pediatric Cancer Research Foundation and the Doris Duke Charitable Foundation. Conflict of Interest Statement: There are no conflicts of interest to report.

Rare diseases affect over 300 million people worldwide and are gaining recognition as a global health priority. Their inclusion in the UN Sustainable Development Goals, the UN Resolution on Addressing the Challenges of Persons Living with a Rare Disease, and the anticipated WHO Global Network for Rare Diseases and WHO Resolution on Rare Diseases, which is yet to be announced, emphasise their significance. People with rare diseases often face unmet health needs, including access to screening, diagnosis, therapy, and comprehensive health care. These challenges highlight the need for awareness and targeted interventions, including comprehensive education, especially in primary care. The majority of rare disease research, clinical services, and health systems are addressed with specialist care. WHO Member States have committed to focusing on primary health care in both universal health coverage and health-related Sustainable Development Goals. Recognising this opportunity, the International Rare Diseases Research Consortium (IRDiRC) assembled a global, multistakeholder task force to identify key barriers and opportunities for empowering primary health-care providers in addressing rare disease challenges.

OBJECTIVE The superior effect of Roux-en-Y gastric bypass (RYGB) on glucose control compared with laparoscopic adjustable gastric banding (LAGB) is confounded by the greater weight loss after RYGB. We therefore examined the effect of these two surgeries on metabolic parameters matched on small and large amounts of weight loss. RESEARCH DESIGN AND METHODS Severely obese individuals with type 2 diabetes were tested for glucose metabolism, β-cell function, and insulin sensitivity after oral and intravenous glucose stimuli, before and 1 year after RYGB and LAGB, and at 10% and 20% weight loss after each surgery. RESULTS RYGB resulted in greater glucagon-like peptide 1 release and incretin effect, compared with LAGB, at any level of weight loss. RYGB decreased glucose levels (120 min and area under the curve for glucose) more than LAGB at 10% weight loss. However, the improvement in glucose metabolism, the rate of diabetes remission and use of diabetes medications, insulin sensitivity, and β-cell function were similar after the two types of surgery after 20% equivalent weight loss. CONCLUSIONS Although RYGB retained its unique effect on incretins, the superiority of the effect of RYGB over that of LAGB on glucose metabolism, which is apparent after 10% weight loss, was attenuated after larger weight loss.

The value of corticosteroids in the treatment of acute croup has not been clearly established. Martensson et al., Novik, and Coffin have claimed that the course of the disease has been shortened while Leegaard and Turner and Morgan do not feel that the corticosteroids affect its course. The review by Hawkins allowed no conclusions. To resolve this question, a double blind study was conducted on a random sampling of fifty (50) hospital cases of acute croup. Materials and Methods Fifty patients were admitted to the hospital for the treatment of acute "croup." All patients with acute respiratory infections characterized by hoarseness, inspiratory stridor, and a barking cough were included.

BACKGROUND: Placenta accreta is a rare event in pregnancy and may cause life-threatening hemorrhage. This obstetric complication is a diagnostic and management challenge. When the condition is diagnosed, medical management is usually employed first for hemostasis. If the bleeding cannot be controlled, conservative surgical management is attempted, but hysterectomy is often required for definitive care. CASE: The diagnosis of placenta accreta was made intraoperatively at cesarean section undertaken for breech presentation. The placenta was densely adherent to the anterior lower uterus. Severe hemorrhage, which resulted from attempts to manually remove it, was treated with oxytocin, carboprost tromethamine and methylergonovine without success. The uterus was everted to provide access to the placental site, which was excised; the myometrial defect was sutured closed. Three Foley balloons were used to provide uterine tamponade. Methotrexate was administered prophylactically. These measures effectively controlled the hemorrhage. CONCLUSION: Because placenta accreta might not be diagnosed antepartum or during labor, especially when no risk factors are present, adequate preparations cannot be made. If it is diagnosed at the time of cesarean section, a combined conservative approach may prove helpful in controlling bleeding and avoid hysterectomy and hypovolemia.

In Brief BACKGROUND: Avitaminosis can result from the acute malnutrition associated with prolonged pregnancy-related hyperemesis. Serious complications may arise from thiamine deficiency under these circumstances. CASE: We review the relevant literature and describe a case with central nervous system involvement presenting with typical manifestations of Wernicke’s encephalopathy, apparently precipitated by a combination of hyperemesis gravidarum, diabetic ketoacidosis, and intravenous glucose administration. CONCLUSION: While this life-threatening complication is rare, it is important for all who care for obstetric patients to be aware of it and alert to its development. Early recognition is critical given the need to treat affected women expeditiously to help avoid potentially fatal adverse consequences. Prophylactic thiamine supplementation should be considered in the care of gravidas with hyperemesis. Acute thiamine deficiency due to hyperemesis gravidarum may cause life-threatening Wernicke’s encephalopathy, particularly if compounded by diabetic ketoacidosis and intravenous glucose administration.

BACKGROUND: Hemorrhage is a serious threat with placenta accreta, often requiring aggressive operative intervention by hysterectomy and resuscitative measures with large-volume blood replacement to ensure survival. Refusal to accept transfusion makes management especially difficult. CASE: We report a Jehovah's Witness patient who had 9 previous cesarean deliveries and presented with anemia and placenta previa percreta invading the bladder wall. Management objectives were to enhance the patient's status, using erythropoietin and autologous transfusion, and to minimize the chance of hemorrhage by prophylactic uterine artery embolization. The placenta was left in situ after the delivery with no untoward consequences. Methotrexate was held in readiness, but was not required as adjuvant therapy. CONCLUSION: Effective care of such patients requires close collaborative team effort and advanced planning to ensure a good outcome.

Objective: Most Americans spend an average of 8 hours per day in the workplace. Current understanding of eating behaviours in the workplace and their association with overweight, obesity and binge eating disorder (BED) is limited. Workplace eating behaviours and weight-related self-efficacy were examined in a sample of 98 individuals with overweight or obesity, with or without BED. Design: Participants completed the Weight Efficacy Lifestyle Questionnaire, Work and Social Adjustment Scale, Worker's Perception of Environmental Factors, and a Workplace Questionnaire. Results: Eating unplanned food occurred on average 2.43 times per week (SD = 3.37), and eating unplanned food even when meals were brought from home occurred on average 1.28 times per week (SD = 1.84). Individuals with BED purchased lunch even when they brought food from home significantly more frequently than did individuals without BED. Those with BED also reported significantly poorer work and social adjustment related to binge eating as compared with those without BED. The most significant barriers to healthy eating in the workplace were coworker influence, eating more food in general and more junk food in response to stress, eating unplanned food at work and time constraints. Conclusions: These factors may be important to target in weight-loss treatment to increase individuals' weight loss success. As individuals with BED may be the most vulnerable to eating unplanned foods, clinicians may want to focus on this potential barrier in BED treatment.