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Background In urbanized, low-income cities with high rates of congestion, delivery of antiepileptic drugs (AEDs) by unmanned aerial vehicles (drones) to people with epilepsy for both emergency and non-urgent distribution may prove beneficial. Methods Conakry is the capital of the Republic of Guinea, a low-income sub-Saharan African country (2018 per capita gross national income US$830). We computed the number of drones and delivery times to distribute AEDs from a main urban hospital to 27 pre-identified gas stations, mosques and pharmacies and compared these to the delivery times of a personal vehicle. Results We predict that a single drone could serve all pre-identified delivery locations in Conakry within a 20.4-h period. In an emergency case of status epilepticus, 8, 20 and 24 of the 27 pre-identified destinations can be reached from the hub within 5, 10 and 15 min, respectively. Compared with the use of a personal vehicle, the response time for a drone is reduced by an average of 78.8% across all times of the day. Conclusions Drones can dramatically reduce the response time for both emergency and routine delivery of lifesaving medicines. We discuss the advantages and disadvantages of such a drone delivery model with relevance to epilepsy. However, the commissioning of a trial of drones for drug delivery in related diseases and geographies is justified.

Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in a pandemic which has infected more than 128 million people and led to over 2.8 million deaths worldwide. Although the introduction of efficacious vaccines has led to overall declines in the incidence of SARS-CoV-2 infection, there has been a recent increase in infections once more due to the appearance of mutant strains with higher virulence. It therefore remains vital to identify predictors of poor outcomes in this patient population. Purpose The objective of our study was to identify predictors of prolonged hospitalization, intensive care unit (ICU) admission, intubation, and death in patients infected with SARS-CoV-2. Methods We conducted a retrospective analysis of all patients hospitalized with SARS-CoV-2 at our health system that includes one tertiary care center and two community hospitals located in the Chicago metropolitan area. The main outcome was a composite endpoint of hospitalization >28 days, ICU admission, intubation, and death. Explanatory variables associated with the primary outcome in the bivariate analysis (p Results Between March 1, 2020 and May 31, 2020, 1029 patients hospitalized with SARS-CoV-2 were included in our analysis. Of these patients, 379 met the composite endpoint. Baseline demographics are described in Table 1. Of note, our cohort consisted of a predominantly minority patient population including 47% Hispanic, 17% African American, 16% Caucasian, and 16% other. In bivariate analysis, age, hypertension, tobacco and alcohol abuse, obesity, coronary artery disease, arrhythmias, valvular heart disease, dyslipidemia, hypertension, stroke, diabetes, documented thrombosis, troponin, CRP, ESR, ferritin, LDH, BNP, D-dimer >5x the upper limit of normal, lactate, and right ventricular outflow tract velocity time integral After multivariable adjustment, explanatory variables associated with the composite endpoint included troponin (OR 2.36; 95% CI 1.08–5.17, p 0.03), D-dimer (OR 1.5; 95% CI 1.23–1.98, p Conclusions In a large urban cohort with a predominantly minority population, we identified several clinical predictors of poor outcomes. Of note, race was not a predictor of the primary endpoint in this study. While recent literature has demonstrated worse outcomes among racial minorities infected with SARS-CoV-2, our data suggests these variations are related to social determinants of health rather than biologic causes. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Loyola University Medical Center

Background People with substance use disorders are considered at increased risk of COVID-19 and its more serious complications, however data on the impact of COVID-19 are lacking. The study aimed to describe the clinical characteristics and outcomes of COVID-19 on people with substance use disorders. Methods an observational study was carried out including patients aged ≥ years with COVID-19 pneumonia admitted to an urban hospital during March 12 to June 21,2020. Results Among 2078 patients admitted, 27 (1.3%) were people with substance use disorders: 23(85.2%) were men with a median age of 56.1 + 10.3 years and. The main SUD were alcohol in 18(66.7%) patients, heroine in 6(22.2%) and cocaine in 3(11.1%) and 24(88.8%) patients were on ongoing substance use disorder treatment. One or more comorbidities associated to COVID-19 risk were observed in 18(66.6%) of patients. During a median length of stay of 10 days (IQR:7-19), severe pneumonia developed in 7(25.9%) patients, acute respiratory distress syndrome in 5 (18.5%) and none died. Conclusion Larger sample sizes and sero-epidemiological studies are needed to confirm the low incidence of severe COVID-19 on patients with SUD.

Purpose The integration of pharmacy residents into an antimicrobial stewardship program (ASP) is described, and data on the residents’ ASP interventions and outcomes are reported. Summary ASP coverage of nighttime, holiday, and weekend shifts is often provided by infectious diseases (ID) medical fellows and staff pharmacists, potentially leading to inconsistent stewardship practices. As part of an initiative by a large urban hospital to provide around-the-clock, comprehensive ASP services 7 days a week, postgraduate year 2 (PGY2) pharmacy residents in ID or critical care were assigned to provide ASP coverage on weekends. Over a 12-month period, residents providing ASP weekend coverage documented a total of 1,443 interventions, of which 1,000 (69%) were pursuant to 72-hour prospective audit and feedback review and 443 (31%) occurred during ASP phone coverage. A comparison of overall antimicrobial utilization (mean ± S.D. days of therapy [DOT] per 1,000 patient-days [PD]) before and after implementation of resident ASP coverage on weekends showed a decrease in aggregate antimicrobial use from 799.3 ± 46.8 to 740.7 ± 17.3 DOT/1,000 PD (a difference of 58.6 DOT/1,000 PD, p = 0.08), with a corresponding decline in the incidence of hospital-onset Clostridium difficile infection (from 1.18 cases to 0.9 case per 1,000 PD). Conclusion By expanding the hospital’s ASP services by assigning PGY2 pharmacy residents to weekend coverage, the institution was able to provide high-level clinical care 7 days per week, which benefited both patients and PGY2 pharmacy residents while meeting national ASP regulatory requirements.

Background Takotsubo (stress) cardiomyopathy is an acute reversible heart failure syndrome initially described in Japanese patients, but now well characterized in Caucasians patients in Europe or of European descent. An initial observation has suggested a lower incidence of Takotsubo in non-Caucasian subjects, particularly in the African-American (AA) population in the United States of America. The purpose of this study was to assess whether epidemiologic and clinical differences were present in Takotsubo in a large urban hospital in Virginia, USA. Methods We used an informatics-based system to query electronic health records (TriNetX, Cambridge, MA, USA) to search for cases of Takotsubo between 2010 and 2018 and a corresponding cohort of patients with non-ST segment elevation acute myocardial infarction (NSTEMI). We then performed a chart-level review of 160 cases and obtained additional clinical information including symptoms, risk factors, co-morbidities, and in-hospital outcomes. This retrospective study was approved by the Institutional Review Board of our institution. Results We identified 260 cases of Takotsubo and 6,270 of NSTEMI in the same time period (1:24, 4.2%). Being AA was associated with an odds ratio of Takotsubo versus NSTEMI of 0.38 [0.29–0.50] (P=0.0001). With further evaluation of patients with Takotsubo (N=160), AA (N=44, 27.2%) and Non-Hispanic Caucasian (C) (N=110, 67.9%) had no differences in age and sex. AA patients with Takotsubo however were more likely than C patients to be affected by type II diabetes mellitus (38.6% versus 14.5%, P=0.002, OR 3.70 [1.65–8.28]), have history of drug abuse (27.3% versus 9.1%, P=0.009, OR 3.75 [1.48–9.49]) and of cocaine use in particular (9.1% versus 0.9%, P=0.024, OR 11.0 [1.19–101.4]). The pattern of wall motion abnormality was not different between the 2 groups. AA patients presented with a lower ratio of brain natriuretic peptide (BNP) to troponin I (41.9 [12.7–258] pg./ml versus 281 [42–890] pg/ml, P=0.022). There was no significant difference of in-hospital mortality between the AA and C groups (9.1% versus 25%, respectively, OR 0.40 [0.13–1.24], P=0.11). Conclusions The incidence and clinical characteristics of Takotsubo (stress) cardiomyopathy appear to be different between African-American and Non-Hispanic Caucasian patients. African-American patients are more likely to have diabetes and illicit drug usage, but have a lower BNP/troponin I ratio. Both AA and Non-Hispanic Caucasian patients have similar in-hospital mortality.

Traditionally, morning blood draws are collected by hospital staff from 3:00 AM through 6:00 AM to have the results ready by 9:00 AM for physician rounds. These laboratory results help physicians to make important patient disposition decisions, including discharging patients within the daily hospital cutoff times. However, morning draws can adversely impact patient care due to sleep disruption. In this paper, we describe the systematic implementation of later-morning blood draw times at our large urban hospital. The sustainability of this shift was of special concern to us, so we used the rapid improvement model (RIM) of change to ensure that every aspect was tested and that the changes were viable. The RIM model enabled us to successfully implement the change in 6 months and sustained this change until the present time.

Background COVID-19 is an emerging pathogen that has caused a global pandemic, with New York City as one of its epicenters. Data are still forthcoming if pregnant women are more vulnerable to COVID-19, as they are with influenza. Additionally, it is not known if infants born to COVID-19 positive women are at risk of being infected at birth. Methods In March 2020, our hospital instituted a policy of testing all pregnant women presenting for active labor and scheduled C-section or induction of labor, with a nasopharyngeal swab that was sent for RT-PCR qualitative SARS-CoV-2 assay (Roche Cobas® 6800). Upon birth, infants were also tested, unless the parent did not give consent. We retrospectively reviewed the COVID-19 test results of all pregnant women and their infants, from March 23 through May 31, 2020 using our infection control surveillance system (VigiLanz®). We also reviewed the electronic medical record (EPIC®) for documentation of any symptoms consistent with COVID-19 infection either prior to hospitalization or during the hospital stay. Results A total of 415 women and 72 infants were tested for SARS-CoV-2. Of the 415 women tested, 41 (9.9%) were positive. Of the 72 infants tested, 2 (2.8%) were positive and concordant with their birth parent. Only 1 (2.4%) of the women who tested positive was symptomatic. The remaining 40 (97.6%) women did not report any symptoms of COVID-19 during labor. Neither of the two positive infants displayed any signs or symptoms of COVID-19. Of the 41 women who were positive, 5 did not consent to have their infant tested. The one symptomatic woman who tested positive for COVID-19 had an infant who tested negative by PCR. Conclusion During the first wave of the COVID-19 pandemic, we found 9.9% (41/415) of pregnant women presenting for labor tested positive for SARS-CoV-2. Among the 41 women who tested positive, only 1 (2.4%) had symptoms on presentation and only 2 newborn infants tested positive. Our data suggests that pregnant women may not be at increased risk for complications from COVID-19 disease and are not likely to transmit the disease to their infants during labor. Disclosures All Authors: No reported disclosures

Background Despite the high efficacy of PrEP, it continues to be underutilized. We examined the extent to which patients with a documented positive test for STIs were provided PrEP at an urban municipal medical center. Methods We reviewed data of all patients seen between January 1, 2014 and July 30, 2017 who were > 18 years old and had an initial HIV negative test and ≥1 positive test for Chlamydia, Gonorrhea, or Syphilis. We examined PrEP prescription data by gender, race/ethnicity, and clinic location. Differences between groups were compared using Chi-squared analysis and logistic regression. Results Of 1,142 initially HIV− patients who were identified as having a positive STI result, 52% were female, 89% either Black or Hispanic, with a median age of 40 years (quartiles 30, 47). 58% had Medicare/Medicaid and 34% were self-pay or uninsured (Table 1). Only 25 (2.1%) of 1,142 patients who had ≥1 STI test positive were prescribed PrEP. No women received PrEP. Whites (aOR: 21.7 [95% CI:4.4, 107, P < 0.001] and Hispanics (aOR:6.64 [95% CI:1.35, 32.8, P = 0.02] were both more likely to receive PrEP than Blacks, after adjusting for age, sex, marital status, and insurance. All PrEP prescriptions originated from the Medicine, Emergency, or HIV specialty clinics although most STI testing was obtained in Emergency and Obstetrical/Gynecological clinics (Table 2). Conclusion There were significant missed opportunities for HIV prevention among patients with STIs within the medical center, particularly among Hispanic and Black patients. Enrichment programs to educate providers and increase PrEP prescriptions may have a major impact on expanding HIV prevention, especially for women. Disclosures All authors: No reported disclosures.

Background Due to increasing global travel and evolving epidemiologic factors, the number of incident cases of malaria imported into the United States has been growing in recent years. Methods We conducted a retrospective review of 90 cases of malaria seen at a single urban university hospital during 2000–2016. Results Of the 90 cases, 77% were Plasmodium falciparum, 14% were either P. ovale or P. vivax, 1% was P. malariae, and the rest were mixed or unknown. Eighty-one patients had traveled to Africa, four to Asia, four to more than one continent, and one to Haiti. Mean age was 41, and 59% were male. The main presenting symptoms were fever (92%), chills (78%), and headache (66%); 10% presented with cerebral malaria. Thirteen cases were managed as outpatients, 59 on a medical ward, and 18 in the ICU. Fourteen (16%) had severe malaria; these were more likely to present with hypotension, non-segmented neutrophilia, hyponatremia, metabolic acidosis, and acute kidney injury (all P < 0.01). Thrombocytopenia was more severe in patients with severe malaria (54,000 vs. 113,000, P < 0.01). Treatment included quinine-based therapy (38%), atovaquone/proguanil (31%), artemether/lumefantrine (19%), and chloroquine/primaquine (11%). Twenty (22%) required change of treatment regimen due to inadequate clinical response or adverse effects. The most common in-hospital complications were ARDS (8%), QT prolongation (7%), and nosocomial infection (4%). Two patients were pregnant at the time of presentation; one suffered severe malaria and fetal loss. Only 3% of patients reported being prescribed a prophylactic regimen and completing it; 20% reported taking an incomplete course, and the majority took no prophylaxis at all. Of 27 patients who had presented to another United States-based medical provider prior to hospitalization, 11 were initially misdiagnosed and treated for conditions other than malaria, including two who underwent extensive hematologic investigations. Inadequate experience and resources in treating malaria were the primary reasons cited for transfer to the tertiary hospital from community-based providers. Conclusion Malaria poses a substantial health risk to US travelers, particularly in light of under-utilization of prophylaxis, lack of familiarity with the disease by local providers, and delays to diagnosis. Disclosures All authors: No reported disclosures.

There are limited published data on the labelling of single unit dose packages in hospitals.The study was conducted in three large hospitals (two adult and one paediatric) in the metropolitan Montreal area, Quebec, Canada.The objective is to evaluate the labelling of commercial oral single solid unit dose packages available in Canadian urban hospital pharmacy practice.The study endpoint was the labelling conformity of each unit dose package for each criterion and overall for each manufacturer. Complete labelling of unit dose packages should include the following information: (1) brand name, (2) international non-proprietary name or generic name, (3) dosage, (4) pharmaceutical form, (5) manufacturer's name, (6) expiry date, (7) batch number and (8) drug identification number. We also evaluated the ease with which a single unit dose package is detached from a multiple unit dose package for quick, easy and safe use by pharmacy staff. Conformity levels were compared between brand-name and generic packages.A total of 124 different unit dose packages were evaluated. The level of conformity of each criterion varied between 19 and 50%. Only 43% of unit dose packages provided an easy-to-detach system for single doses. Among the 14 manufacturers with three or more unit dose packages evaluated, eight (57%) had a conformity level less than 50%.This study describes the conformity of commercial oral single solid unit dose packages in hospital pharmacy practice in Quebec. A large proportion of unit dose packages do not conform to a set of nine criteria set out in the guidelines of the American Society of Health-System Pharmacists and the Canadian Society of Hospital Pharmacists.

OBJECTIVE: The frequency and causes of ab- errant International Normalized Ratios (INRs) in warfarin recipients and the percentage explainable by warfarin nonadherence were studied. METHODS:The medical records of patients whose warfarin therapy was monitored by a telephone-based anticoagulation service in a Midwestern urban hospital between March 2000 and March 2001 were reviewed for causes of out-of-range INRs, the percentage of out-of-range INRs attributable to warfarin nonadherence, and demographic and clinical variables predictive of nonadherence. RESULTS:Data from 347 patients were studied. The cohort yielded 4305 INRs, of which 1002 (23%) were out of range (lower than 1.8 or higher than 3.4). Thirty-six percent of the out-of-range INRs were due to warfarin or dietary nonadherence, 9% were due to medical systems problems (including drug interactions), 18% were due to a change in clinical status, and 38% were idiopathic. Age younger than 65 years, age greater than 80 years, and living closer to the laboratory were predictive of warfarin nonadherence. CONCLUSION:Warfarin nonadherence was the most common cause of explainable aberrant INRs in patients taking warfarin. Age younger than 65 years, age greater than 80 years, and living close to the laboratory were predictive of warfarin nonadherence.

We analyze a recently proposed temporal centrality measure applied to an empirical network based on person-to-person contacts in an emergency department of a busy urban hospital. We show that temporal centrality identifies a distinct set of top-spreaders than centrality based on the time-aggregated binarized contact matrix, so that taken together, the accuracy of capturing top-spreaders improves significantly. However, with respect to predicting epidemic outcome, the temporal measure does not necessarily outperform less complex measures. Our results also show that other temporal markers such as duration observed and the time of first appearance in the the network can be used in a simple predictive model to generate predictions that capture the trend of the observed data remarkably well., Comment: 31 pages, 15 figures, 11 tables; typos corrected; references added; Figure 3 added; some changes to the conclusion and introduction

The relationship between theophylline-associated adverse drug reactions (ADRs) and serum theophylline concentration (STC) was studied. Patients with obstructive airway disease who received theophylline on the pulmonary ward of a large urban hospital over a 10-month period were included in the study. Each patient was interviewed within two hours after collection of a sample for determining STC and, without knowing the STC, the interviewer classified each patient into one of the following categories: ADR, no ADR, or indeterminant (symptoms similar to a theophylline-associated ADR but possibly caused by concomitant drugs or comorbidities). ADRs were also classified as to their severity. The interviewer identified 340 ADRs during 201 interviews of 126 patients. All but four of the ADRs were mild. In half of the interviews, patients reported at least two concurrent ADRs. Not including the indeterminant group, ADRs occurred in 69% of the patients, a much higher frequency than previously reported. The mean +/- S.D. STCs for the ADR and no-ADR groups were 6.5 +/- 1.7 and 7.7 +/- 2.0 micrograms/mL, respectively. When the indeterminant ADRs were added to the theophylline-associated ADRs, the resulting group had a mean +/- S.D. STC of 11.5 +/- 3.3 micrograms/mL. No significant association was found between STC and occurrence of ADRs. Theophylline-associated ADRs occurred more frequently than expected at STCs within and below the usually accepted therapeutic range.

BACKGROUND. Economic incentives exist to scrutinize length of stay variations between hospitals. However, the reasons for variations can be complex, and without knowing these the feasibility of shorter stay targets, and their implications for patient outcome, are unclear. METHODS. This research compared care received by patients admitted for fractured neck of femur at an inner-city university teaching hospital, an inner-city associated teaching hospital and an associated teaching hospital in an urban setting. Multiple regression and descriptive analysis were used to examine how in-patient acute stay was affected by the severity of cases on admission and the supply of beds beyond the acute setting. Data on patient outcome were mortality up to three months post fracture and functional ability at in-patient discharge and three months post fracture. RESULTS. A total of 492 patients were recruited. Patient outcomes at three months were similar at the hospitals. Multiple regression revealed significant differences between the patient stay of the inner-city teaching hospital and the urban associated teaching hospital. A difference in stay of around 14 days was demonstrated, with the urban hospital having the shorter stay. These differences were linked it to having a greater supply of non-acute beds. CONCLUSION. Significant differences in patient stay between hospitals can be due to factors beyond the direct control of the acute unit. Economic incentives may mean that purchasers and providers ignore a full analysis of these factors and set length of stay targets which are not feasible in the short term. This could reduce the quality and impair the outcome of patient care

Analytical data from the clinical toxicology laboratory of a large urban hospital, the Los Angeles County--University of Southern California Medical Center, are reported for the year 1976 and are compared to similar data previously documented for the year 1972. Drugs assayed, number of tests requested, and number of positive results are collated. Data on 58 assays show that the overwhelming majority of the requests continue to be for those tests that were originally classified as tests with 4-h turn-around time in the patient-focused concept for a clinical toxicology service in 1972. Total workload increased by 70%. The number of patients on whom some toxicologic assay was requested doubled in spite of a decrease in the number of patients admitted to the hospital during this five-year period. The data show that assays for some socially and clinically significant drugs--ethanol diazepam, tricyclics, and phencyclidine--increased disproportionally while others remained relatively constant, or even decreased.

We report one year's analytical data from a clinical toxicology laboratory of a large urban hospital. The laboratory was designed to perform tests on seriously ill patients believed to be suffering from possible drug overdose. The data describe the types and numbers of tests requested and percent positive. Barbiturates, ethanol, a "hypnotic screen," phenothiazines, and salicylates were the leading requests and positive findings among the 63 drug determinations studied. The mechanism of organizing a laboratory along "patient-focused" lines is described and the clinician—laboratory interface is discussed. We believe that these data could be of value to anyone contemplating offering a clinical toxicology service for the first time or in assisting in the reorganization of their present service.

From the Mother and Child Health Center (MCHC) in Khon Kaen in the northeast of Thailand 1178 and from the Vajira Hospital in Bangkok 1372 singleton consecutive birth rates were analyzed. Low birth rates (< or = to 2500g) were slightly but significantly higher in Khon Kaen (13.4%) than in Bangkok (10.5%). Low birth weight rates were common for primegravida. This relationship was pronounced in Khon Kaen. Mean birth weights measured 2952 + or - 416g in Khon Kaen and 3028 +or- 444 g in Bangkok. A test of interaction including the location of the hospital occupation and parity on birth weights was positive but failed to be significant for single factors or combinations with the exception of parity. (authors modified.

Lacey is a mutt. Like her mistress, she is gray, dumpy, elderly, slow, non descript. Although there is nothing remarkable about this dog, she does have a peculiar distinction. She is an active casework client in a reputable community agency. As a social worker in a large urban hospital serving an inner-city popula tion, this author seems to have uncov ered a widespread but hitherto unre ported phenomenon—the canine cli ent. It was a colleague, in fact, who first brought it up at a discussion meeting with other colleagues. She re counted her tribulations in attempting to provide custodial care for a pa tient's pet. Her sad ruminations brought forth a chorus of instant rec ognition and the somewhat stunned realization that they had discovered a sleeper in casework practice. A quick check with colleagues in other urban hospitals and nursing homes confirmed that these were not isolated

A retrospective analysis of serotypes and groups of Streptococcus pneumoniae recovered over a 12-year period (1973-1984) from pediatric and adult patients ( > 18 years old) at a large urban hospital is presented. The majority of the 3,302 pneumococcal isolates (2,807, or 85%) were from the respiratory tract, 68% were from adults, and 30% were from children. Of the respiratory isolates from adults, the most common serotypes and groups recovered were, in decreasing order: 3, 19, 9, 23, 4, and 6; and from children, the most common were: 19, 3, 6, 23, 15, and 18. The remaining 15% (495) of the isolates were from patients with either meningitis and/or bacteremia, with 433 (87%) from adults and 62 (13%) from children. From these body sites, the most common types and groups were 4, 3, 8, 14, 9, and 19 from adults and 14, 6, 18, 19, 23, and 4 from children. Approximately 89% of these types and groups are represented in the 23-valent vaccine. Although other investigators have reported corresponding arrays of isolates represented in the vaccine, the contrasts in serotypes underscore regional differences which may be germane to future vaccine formulations.

The usefulness of measuring creatine kinase MB isoenzyme for diagnosing myocardial infarction when activities of total creatine kinase are very high is unclear. We conducted a retrospective study in an urban hospital that serves a largely indigent population. We concentrated on 146 patients whose creatine kinase activity was greater than 1000 U/L (upper limit of normal: 165 U/L for women and 225 U/L for men), with MB isoenzyme greater than 10 U/L and less than 5% of total creatine kinase. The positive predictive value of MB isoenzyme (isoimmune method) values greater than 10 U/L was between 11.6% and 56.8% when the value for total creatine kinase exceeded 1000 U/L. Using different values (MB greater than 4% of total creatine kinase) as positive for myocardial infarction would have resulted in far fewer false-positives, but 10 cases of myocardial infarction would have been missed. The most appropriate cutoff value for MB isoenzyme in this population (total creatine kinase greater than 1000 U/L) was found to be greater than 2% of total creatine kinase.