Preferred Language Mediates Association Between Race, Ethnicity, and Delayed Presentation in Critically Ill Patients With COVID-19

Which social factors explain racial and ethnic disparities in COVID-19 access to care and outcomes remain unclear.

OBJECTIVES

We hypothesized that preferred language mediates the association between race, ethnicity and delays to care.

DESIGN SETTING AND PARTICIPANTS

Multicenter, retrospective cohort study of adults with COVID-19 consecutively admitted to the ICU in three Massachusetts hospitals in 2020.

MAIN OUTCOME AND MEASURES

Causal mediation analysis was performed to evaluate potential mediators including preferred language, insurance status, and neighborhood characteristics.

RESULTS

Non-Hispanic White (NHW) patients (157/442, 36%) were more likely to speak English as their preferred language (78% vs. 13%), were less likely to be un- or under-insured (1% vs. 28%), lived in neighborhoods with lower social vulnerability index (SVI) than patients from racial and ethnic minority groups (SVI percentile 59 [28] vs. 74 [21]) but had more comorbidities (Charlson comorbidity index 4.6 [2.5] vs. 3.0 [2.5]), and were older (70 [13.2] vs. 58 [15.1] years). From symptom onset, NHW patients were admitted 1.67 [0.71-2.63] days earlier than patients from racial and ethnic minority groups (p < 0.01). Non-English preferred language was associated with delay to admission of 1.29 [0.40-2.18] days (p < 0.01). Preferred language mediated 63% of the total effect (p = 0.02) between race, ethnicity and days from symptom onset to hospital admission. Insurance status, social vulnerability, and distance to the hospital were not on the causal pathway between race, ethnicity and delay to admission.

CONCLUSIONS AND RELEVANCE

Preferred language mediates the association between race, ethnicity and delays to presentation for critically ill patients with COVID-19, although our results are limited by possible collider stratification bias. Effective COVID-19 treatments require early diagnosis, and delays are associated with increased mortality. Further research on the role preferred language plays in racial and ethnic disparities may identify effective solutions for equitable care.

Prolonged Prone Position Ventilation Is Associated With Reduced Mortality in Intubated COVID-19 Patients

BACKGROUND

Prone position ventilation (PPV) is resource-intensive, yet the optimal strategy for PPV in intubated patients with COVID-19 is unclear.

RESEARCH QUESTION

Does a prolonged (24 or more h) PPV strategy improve mortality in intubated COVID-19 patients compared with intermittent (∼16 h with daily supination) PPV?

STUDY DESIGN AND METHODS

Multicenter, retrospective cohort study of consecutively admitted intubated COVID-19 patients treated with PPV between March 11 and May 31, 2020. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 90-day all-cause mortality and prone-related complications. Inverse probability treatment weights (IPTW) were used to control for potential treatment selection bias.

RESULTS

Of the COVID-19 patients who received PPV, 157 underwent prolonged and 110 underwent intermittent PPV. Patients undergoing prolonged PPV had reduced 30-day (adjusted hazard ratio [aHR], 0.475; 95% CI, 0.336-0.670; P < .001) and 90-day (aHR, 0.638; 95% CI, 0.461-0.883; P = .006) mortality compared with intermittent PPV. In patients with Pao2/Fio2 ≤ 150 at the time of pronation, prolonged PPV was associated with reduced 30-day (aHR, 0.357; 95% CI, 0.213-0.597; P < .001) and 90-day mortality (aHR, 0.562; 95% CI, 0.357-0.884; P = .008). Patients treated with prolonged PPV underwent fewer pronation and supination events (median, 1; 95% CI, 1-2 vs 3; 95% CI, 1-4; P < .001). PPV strategy was not associated with overall PPV-related complications, although patients receiving prolonged PPV had increased rates of facial edema and lower rates of peri-proning hypotension.

INTERPRETATION

Among intubated COVID-19 patients who received PPV, prolonged PPV was associated with reduced mortality. Prolonged PPV was associated with fewer pronation and supination events and a small increase in rates of facial edema. These findings suggest that prolonged PPV is a safe, effective strategy for mortality reduction in intubated COVID-19 patients.

Code status orders in patients admitted to the intensive care unit with COVID-19: a retrospective cohort study

Purpose

Materials and methods

Results

Conclusions

Jailers at the Bedside: Ethical Conflicts in Provision of Community Hospital Care for Incarcerated Individuals

Incarcerated individuals in the United States are frequently transferred to hospitals in the community setting for specialized medical care beyond the capability of on-site facilities. Despite the widespread prevalence of this practice, hospitals set their own policies for the care of these vulnerable patients, which are often in conflict with broadly accepted principles of medical ethics. This article explores common practices of community hospitals in caring for incarcerated individuals and argues for the need for further research and, ultimately, reform in this neglected area.

A mathematical model of the Drosophila circadian clock with emphasis on posttranslational mechanisms

Experimental evidence points increasingly to the importance of posttranslational processes such as phosphorylation and translocation in the molecular circadian clocks of many organisms. We develop a mathematical model of the Drosophila circadian clock that incorporates the emerging details of the timing of nuclear translocation of the PERIOD and TIMELESS proteins. Most models assume that these proteins enter the nucleus as a complex, but recent experiments suggest that they in fact enter the nucleus separately. Our model reproduces observed patterns of intracellular localization of PERIOD and TIMELESS during light-dark cycles and in constant darkness, as well as phenotypes of several clock mutants. We also use the model to demonstrate how the Drosophila clock can exhibit robust oscillations with constant mRNA levels of period or timeless, and propose a possible mechanism for oscillations in double-rescue experiments of per(01)-tim(01) mutants. The model also explains (via posttranslational processes) the counter-intuitive observation that total dCLOCK levels are at their lowest at the circadian time when active nuclear dCLOCK must be peaking in order to activate transcription of other clock genes, implying that for dCLOCK a posttranslationally generated rhythm is more important than the transcriptionally generated rhythm. These results support the idea that posttranslational processes play key roles in generating as well as modulating robust circadian oscillations. While it appears that posttranslational mechanisms alone are not sufficient to generate rhythms in Drosophila, posttranslational mechanisms can greatly amplify a very weak transcriptional rhythm.