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Background Obesity is a risk factor for pneumonia and acute respiratory distress syndrome. Objective To determine whether obesity is associated with intubation or death, inflammation, cardiac injury, or fibrinolysis in coronavirus disease 2019 (COVID-19). Design Retrospective cohort study. Setting A quaternary academic medical center and community hospital in New York City. Participants 2466 adults hospitalized with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection over a 45-day period with at least 47 days of in-hospital observation. Measurements Body mass index (BMI), admission biomarkers of inflammation (C-reactive protein [CRP] level and erythrocyte sedimentation rate [ESR]), cardiac injury (troponin level), and fibrinolysis (D-dimer level). The primary end point was a composite of intubation or death in time-to-event analysis. Results Over a median hospital length of stay of 7 days (interquartile range, 3 to 14 days), 533 patients (22%) were intubated, 627 (25%) died, and 59 (2%) remained hospitalized. Compared with overweight patients, patients with obesity had higher risk for intubation or death, with the highest risk among those with class 3 obesity (hazard ratio, 1.6 [95% CI, 1.1 to 2.1]). This association was primarily observed among patients younger than 65 years and not in older patients (P for interaction by age = 0.042). Body mass index was not associated with admission levels of biomarkers of inflammation, cardiac injury, or fibrinolysis. Limitations Body mass index was missing for 28% of patients. The primary analyses were conducted with multiple imputation for missing BMI. Upper bounding factor analysis suggested that the results are robust to possible selection bias. Conclusion Obesity is associated with increased risk for intubation or death from COVID-19 in adults younger than 65 years, but not in adults aged 65 years or older. Primary funding source National Institutes of Health.

From August 15, 2015 to March 5, 2016, Tanzania reported 16,521 cholera cases and 251 deaths, with 4,596 cases and 44 deaths in its largest city, Dar es Salaam. To evaluate outbreak response efforts, we conducted a household survey with drinking water testing in the five most affected wards in Dar es Salaam. We interviewed 641 households 6 months after the beginning of the outbreak. Although most respondents knew that cholera causes diarrhea (90%) and would seek care if suspecting cholera (95%), only 45% were aware of the current outbreak in the area and only 5% would use oral rehydration salts (ORS) if ill. Of 200 (31%) respondents reporting no regular water treatment, 46% believed treatment was unnecessary and 18% believed treatment was too expensive. Fecal contamination was found in 45% of water samples and was associated with water availability (P = 0.047). Only 11% of samples had detectable free chlorine residual, which was associated with water availability (P = 0.025), reported current water treatment (P = 0.006), and observed free chlorine product in the household (P = 0.015). The provision of accessible, adequately chlorinated water supply, and implementation of social mobilization campaigns advocating household water treatment and use of ORS should be prioritized to address gaps in cholera prevention and treatment activities.

Background Histoplasmosis is a fungal infection associated with exposure to bat guano. An outbreak of an unknown severe febrile illness occurred among tunnel workers in the Dominican Republic, and resulted in several deaths. We conducted an investigation to confirm etiology and recommend control measures. Methods A case was defined as fever and ≥2 symptoms consistent with histoplasmosis in a tunnel worker, July-September 2015. We interviewed workers and family members, reviewed medical records, tested serum and urine for Histoplasma antigen/antibody, and conducted a cohort study to identify risk factors for histoplasmosis and severe infection (intensive care). Results A crew of 36 male workers removed large amounts of bat guano from tunnels without respiratory protection for a median of 24 days per worker (range, 1-25 days). Median age was 32 years (range, 18-62 years); none were immunocompromised. Thirty (83%) workers had illness that met the case definition, of whom 28 (93%) were hospitalized, 9 (30%) required intensive care, 6 (20%) required intubation, and 3 (10%) died. The median time from symptom onset to antifungal treatment was 6 days (range, 1-11 days). Twenty-two of 34 (65%) workers had laboratory evidence of infection. Conclusions Severe illnesses and death likely resulted from exposure to large inocula of Histoplasma capsulatum spores in an enclosed space, lack of respiratory protection, and delay in recognition and treatment. Clinician education about histoplasmosis, improved laboratory capacity to diagnose fungal infections, and occupational health guidance to protect workers against endemic fungi are recommended in the Dominican Republic.

BACKGROUND AND OBJECTIVES: Diagnostic codes are used widely within health care for billing, quality assessment, and to measure clinical outcomes. The US health care system will transition to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), in October 2015. Little is known about how this transition will affect pediatric practices. The objective of this study was to examine how the transition to ICD-10-CM may result in ambiguity of clinical information and financial disruption for pediatricians. METHODS: Using a statewide data set from Illinois Medicaid specified for pediatricians, 2708 International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes were identified. Diagnosis codes were categorized into 1 of 5 categories: identity, class-to-subclass, subclass-to-class, convoluted, and no translation. The convoluted and high-cost diagnostic codes (n = 636) were analyzed for accuracy and categorized into “information loss,” “overlapping categories,” “inconsistent,” and “consistent.” Finally, reimbursement by Medicaid was calculated for each category. RESULTS: Twenty-six percent of pediatric diagnosis codes are convoluted, which represents 21% of Illinois Medicaid pediatric patient encounters and 16% of reimbursement. The diagnosis codes represented by information loss (3.6%), overlapping categories (3.2%), and inconsistent (1.2%) represent 8% of Medicaid pediatric reimbursement. CONCLUSIONS: The potential for financial disruption and administrative errors from 8% of reimbursement diagnosis codes necessitates special attention to these codes in preparing for the transition to ICD-10-CM for pediatric practices.

What role do students have in global health activities? On one hand, students have much to offer, including

Background On August 11, 2016, Hospital A notified Kentucky Department for Public Health of 2 carbapenemase-producing (CP) carbapenem-resistant Enterobacteriaceae (CRE) identified from clinical cultures from patients without CRE risk factors, including limited prior health care exposure and short hospitalizations. This hospital had no previously reported CRE infections. We investigated to identify and provide recommendations on patient exposures, additional cases, and environmental reservoirs. Methods A case was defined as any CRE culture collected at Hospital A January 1–December 12, 2016. Case finding was conducted by using laboratory records and screening cultures of patients. Patient exposures were identified through medical chart abstraction, patient interviews, and environmental sampling. Results In addition to 2 initial cases, 21 additional cases were identified. Three Enterobacteriaceae genera (Klebsiella pneumoniae [17], Escherichia coli [5], and Enterobacter cloacae [1]) and 2 carbapenemases were identified. Sixteen of 21 admitted patients (76%) were CRE positive

Physician interest in global health, particularly among family physicians, is reflected by an increasing proliferation of field training and service experiences. However, translating initial training involvement into a defined and sustainable global health career remains difficult and beset by numerous barriers. Existing global health literature has largely examined training experiences and related ethical considerations while neglecting the role of career development in global health. To explore this, this paper extrapolates potential barriers to global health career involvement from existing literature and compares these to salary and skills requirements for archetypal physician positions in global health, presenting a framework of possible barriers to sustained physician participation in global health work. Notable barriers identified include financial limitations, scheduling conflicts, security/family concerns, skills limitations, limited awareness of opportunities, and specialty choice, with family practice often closely aligned with global health experience. Proposed solutions include financial support, protected time, family relocation support, and additional training. This framework delineates barriers to career involvement in global health by physicians. Further research regarding these barriers as well as potential solutions may help direct policy and initiatives to better utilize physicians, particularly family physicians, as a valuable global health human resource.

Examining the ethics of long-term, career involvement by physicians in global health work is vital, given growing professional interest and potential health implications for communities abroad. However, current literature remains heavily focused on ethical considerations of short-term global health training experiences. A literature review informed our development of an ethics framework centered on two perspectives: the practitioner perspective, further subdivided into extrinsic and intrinsic factors, and community perspectives, specifically that of the host community and the physician's home community. Some physician factors included cultural/linguistic differences, power imbalances, and sustainable skills/competencies. Receiving community factors included resource limitations, standard of care disparities, and community autonomy. Home community factors focused on the opportunity cost of an unavailable physician who was trained and supported by the local community. Descriptive review permitted comparison with existing short-term literature, noting similarities and differences. Our framework provides a basis for further research and critical analysis of ethical implications of career-long physician global health work.