Demographic features and changing incidence and presentation of Merkel cell carcinoma in a retrospective single-center case series

Merkel cell carcinoma (MCC) is an uncommon aggressive cutaneous neuroendocrine tumor with high mortality. The purpose of this study is to describe the clinical correlates of MCC and identify changing trends over time using a retrospective chart review of 113 cases in a single tertiary center pathology database from 1997 to 2015. MCC occurred mostly in the elderly (median age 77 years), more often in males (n = 60, 53%), was most commonly located on the head and neck region (n = 63, 56%), and most commonly presented on the left side of the body (n = 59, 52%). Overall, there was an increase in MCC diagnoses per year from 1997 to 2015, with 2.3 times more cases diagnosed in the last 3 years of the study period than in the first 3 years. Furthermore, cases diagnosed after 2008 were more likely to occur in younger patients, less than or equal to 77 years of age (OR 2.32, 95% CI 1.08, 4.97, p = 0.04). The median age of diagnosis among females was 76 years and among males was 74 years. There was no change in the overall age of diagnosis among men and a decrease in age of diagnosis among females during the study. There was an overall increase in the MCC cases diagnosed among women, and a slight increase in the proportion of females affected by MCC throughout the course of the study. This retrospective case series elucidates MCC epidemiologic characteristics and describes how incidence, sex, and age at diagnosis have changed over the course of the study.

Limited Secondary Transmission of SARS-CoV-2 in Child Care Programs - Rhode Island, June 1-July 31, 2020

On June 1, 2020, with declines in coronavirus disease 2019 (COVID-19) cases and hospitalizations in Rhode Island,* child care programs in the state reopened after a nearly 3-month closure implemented as part of mitigation efforts. To reopen safely, the Rhode Island Department of Human Services (RIDHS) required licensed center- and home-based child care programs to reduce enrollment, initially to a maximum of 12 persons, including staff members, in stable groups (i.e., staff members and students not switching between groups) in physically separated spaces, increasing to a maximum of 20 persons on June 29. Additional requirements included universal use of masks for adults, daily symptom screening of adults and children, and enhanced cleaning and disinfection according to CDC guidelines.^† As of July 31, 666 of 891 (75%) programs were approved to reopen, with capacity for 18,945 children, representing 74% of the state's January 2020 child care program population (25,749 children).

Homeless Shelter Characteristics and Prevalence of SARS-CoV-2

INTRODUCTION

The unfolding COVID-19 pandemic has predictably followed the familiar contours of well established socioeconomic health inequities, exposing and often amplifying preexisting disparities. People living in homeless shelters are at higher risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) compared to the general population. The purpose of this study was to identify shelter characteristics that may be associated with higher transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

METHODS

We conducted a cross-sectional assessment of five congregate shelters in Rhode Island. Shelter residents 18 years old and older were tested for SARS-CoV-2 from April 19-April 24, 2020. At time of testing, we collected participant characteristics, symptomatology, and vital signs. Shelter characteristics and infection control strategies were collected through a structured phone questionnaire with shelter administrators.

RESULTS

A total of 299 shelter residents (99%, 299/302) participated. Thirty-five (11.7%) tested positive for SARS-CoV-2. Shelter-level prevalence ranged from zero to 35%. Symptom prevalence did not vary by test result. Shelters with positive cases of SARS-CoV-2 were in more densely populated areas, had more transient resident populations, and instituted fewer physical distancing practices compared to shelters with no cases.

CONCLUSION

SARS-CoV-2 prevalence varies with shelter characteristics but not individual symptoms. Policies that promote resident stability and physical distancing may help reduce SARS-CoV-2 transmission. Symptom screening alone is insufficient to prevent SARS-CoV-2 transmission. Frequent universal testing and congregate housing alternatives that promote stability may help reduce spread of infection.

Association between sleep duration and differences between weekday and weekend sleep with body mass index & waist circumference among Black women in Sistertalk II

OBJECTIVES

Examine associations between sleep duration and differences between weekday and weekend sleep with body mass index and waist circumference in a sample of high-risk Black women from the SisterTalk II study.

DESIGN

Cross-sectional analysis of baseline data from an intervention study targeting dietary and physical activity behaviors.

SETTING

Women were recruited from the Providence, RI, USA, area.

PARTICIPANTS

The sample includes 569 middle-aged Black women who were hypertensive or at risk for hypertension.

MEASUREMENTS

Participants self-reported their weekday and weekend sleep duration. Body mass index (BMI) and waist circumference (WC) were objectively measured. Associations between the sleep and anthropometric measures were examined using analysis of variance and multivariable regression models controlling for birthplace, educational attainment, employment status, and annual household income.

RESULTS

25.5% of the sample were very short sleepers (≤6 hrs), 28.8% short sleepers (≥6 to <7 hrs), 40.4% recommended sleepers (≥7 to ≤9 hrs), and 5.3% long sleepers (>9 hrs); 70.7% had a consistent sleep duration (≤2-hour difference between weekday and weekend sleep duration), 21.6% were classified as "weekend snoozers" (>2-hours more sleep on weekends), and 7.7% were classified as "weekend warriors" (>2-hours less sleep on weekends). Compared to recommended sleepers, very short sleepers and long sleepers had significantly greater BMIs, while long sleepers had significantly larger WCs. Being a weekend snoozer was also associated with increased BMI and WC.

CONCLUSIONS

In this sample of high-risk Black women, sleep duration and differences between weekday and weekend sleep were independently associated with excess weight and abdominal obesity.

Bacillus Calmette-Guérin vaccination and clinical characteristics and outcomes of COVID-19 in Rhode Island, United States: a cohort study

Coronavirus disease 2019 (COVID-19) has resulted in a global pandemic, and there is limited data on effective therapies. Bacillus Calmette-Guérin (BCG) vaccine, a live-attenuated strain derived from an isolate of Mycobacterium bovis and originally designed to prevent tuberculosis, has shown some efficacy against infection with unrelated pathogens. In this study, we reviewed 120 consecutive adult patients (≥18 years old) with COVID-19 at a major federally qualified health centre in Rhode Island, United States from 19 March to 29 April 2020. Median age was 39.5 years (interquartile range, 27.0-50.0), 30% were male and 87.5% were Latino/Hispanics. Eighty-two (68.3%) patients had BCG vaccination. Individuals with BCG vaccination were less likely to require hospital admission during the disease course (3.7% vs. 15.8%, P = 0.019). This association remained unchanged after adjusting for demographics and comorbidities (P = 0.017) using multivariate regression analysis. The finding from our study suggests the potential of BCG in preventing more severe COVID-19.

The association of obesity with health insurance coverage and demographic characteristics: a statewide cross-sectional study

We evaluated the statewide burden of obesity and its complications among government and state funded programs (Medicare and Medicaid) and commercial insurance.We calculated the prevalence of obesity and the prevalence of relevant comorbidities among different demographic groups and based on health insurance, among adults (18-65 years old) who visited a statewide health network in the state of Rhode Island, in 2017.The overall prevalence of obesity among 74,089 individuals was 38.88% [Asians 16.77%, Whites 37.49%, Hispanics 44.23%, and Blacks 48.44%]. Medicare or Medicaid beneficiaries were 26% and 27%, respectively, more likely to have obesity than those who had commercial insurance (Odds Ratio:1.26, 95% confidence interval [CI]:1.20-1.32; Odds Ratio:1.27, 95%CI:1.22-1.32). Moreover, Medicaid and Medicare beneficiaries with obesity had a higher prevalence of diabetes compared with privately insured with obesity (10.58% and 10.44% vs 4.45%). Medicare beneficiaries with obesity had a statistically higher prevalence of ischemic heart disease (4.34%, 95%CI: 3.77-4.91) than privately insured (3.21%, 95%CI: 2.94-3.47).Based on statewide data among 18 to 65 years old adults, Medicare and Medicaid provide health coverage to 40% of individuals with obesity and 46% of those with the obesity-related comorbidities and complications. State and federal health care programs need to support and expand obesity-related services and coverage.

SARS-CoV-2 and HIV coinfection: clinical experience from Rhode Island, United States

INTRODUCTION

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has infected >6 million people worldwide since December 2019. Global reports of HIV/SARS-CoV-2 coinfection are limited. To better understand the impact of the coronavirus disease 2019 (COVID-19) pandemic on persons with HIV and improve their care, we present an outpatient and inpatient clinical experience of HIV/SARS-CoV-2 coinfection from Rhode Island, US.

METHODS

We describe outpatient and inpatient preparedness for the COVID-19 pandemic, and present a case series of all known patients with HIV/SARS-CoV-2 coinfection at The Miriam Hospital and Rhode Island Hospital, and The Miriam Hospital Infectious Diseases and Immunology Center, in Providence, Rhode Island, US.

RESULTS AND DISCUSSION

The Infectious Diseases and Immunology Center rapidly prepared for outpatient and inpatient care of persons with HIV and SARS-CoV-2. Between 30 March and 20 May 2020, 27 patients with HIV were diagnosed with SARS-CoV-2. Twenty were male, six female and one transgender female; average age was 49 years; 13/27 were Hispanic and 6/27 were African American. All had HIV viral load <200 copies/mL and were on antiretroviral therapy with CD4 count range 87 to 1441 cells/µL. Twenty-six of the 27 had common COVID-19 symptoms for one to twenty-eight days and most had other co-morbidities and/or risk factors. Nine of the 27 were hospitalized for one to thirteen days; of those, three lived in a nursing home, six received remdesivir through a clinical trial or emergency use authorization and tolerated it well; eight recovered and one died. Overall, 17% of known Center people had HIV/SARS-CoV-2 coinfection, whereas the comparable state-wide prevalence was 9%.

CONCLUSIONS

We highlight challenges of outpatient and inpatient HIV care in the setting of the COVID-19 pandemic and present the largest detailed case series to date from the United States on HIV/SARS-CoV-2 coinfection, adding to limited global reports. The aggregated clinical findings suggest that the clinical presentation and outcomes of COVID-19 appear consistent with those without HIV. Whether SARS-CoV-2 infection is more frequent among persons with HIV remains to be determined. More data are needed as we develop our understanding of how HIV and antiretroviral therapy are affected by or have an impact on this pandemic.

Participation in the Child and Adult Care Food Program is associated with fewer barriers to serving healthier foods in early care and education

BACKGROUND

Early care and education (ECE) is an important setting for influencing young children's dietary intake. There are several factors associated with barriers to healthy eating in ECE, and recent evidence suggests that participation in the Child and Adult Care Food Program (CACFP), the primary national food assistance program in ECE, may be associated with fewer barriers to serving healthier foods. However, no prior studies have examined differences between CACFP participants and non-participants across a large, multi-state sample. This is the first study to examine the association between CACFP participation and barriers to serving healthier foods in ECE using a random sample of directors from two regions across the country.

METHODS

We conducted a cross-sectional survey among a random sample of child care center directors from four states (Massachusetts, North Carolina, Rhode Island, and South Carolina). We conducted logistic and Poisson regression to calculate the odds and incidence rate ratios of reporting 1) no barriers, 2) specific barriers (e.g., cost), and 3) the total number of barriers, by CACFP status, adjusting for covariates of interest.

RESULTS

We received 713 surveys (36% response rate). About half (55%) of centers participated in CACFP. The most prevalent reported barriers to serving healthier foods were cost (42%) and children's food preferences (19%). Directors from CACFP centers were twice as likely to report no barriers, compared to directors from non-CACFP centers (OR 2.03; 95% CI [1.36, 3.04]; p < 0.01). Directors from CACFP centers were less likely to report cost as a barrier (OR = 0.46; 95% [CI 0.31, 0.67]; p < 0.001), and reported fewer barriers overall (IRR = 0.77; 95% CI [0.64, 0.92]; p < 0.01), compared to directors from non-CACFP centers.

CONCLUSIONS

CACFP directors reported fewer barriers to serving healthier foods in child care centers. Still, cost and children's food preferences are persistent barriers to serving healthier foods in ECE. Future research should evaluate characteristics of CACFP participation that may alleviate these barriers, and whether barriers emerge or persist following 2017 rule changes to CACFP nutrition standards.

COVID-19 and Intimate Partner Violence: A Call to Action

The COVID-19 pandemic has escalated the risks and dangers for victims of Intimate Partner Violence (IPV). This article aims to describe the current state of IPV in Rhode Island as well as best practices for IPV screening and intervention using telehealth. We highlight the particular plight of undocumented immigrant victims of IPV and how healthcare providers can be responsive to their unique vulnerabilities and needs.

Public Health Approaches Toward Eliminating Hepatitis C Virus in Rhode Island

Hepatitis C Virus (HCV) continues to be a cause of significant morbidity and mortality around the world surpassing HIV, Tuberculosis and Malaria as the leading cause of death by an infectious disease. In the United States, advances in screening, testing and treatment have put the goal set by the World Health Organization (WHO) to HCV elimination within reach. Rhode Island has taken an innovative public health approach to eliminating HCV by improving disease surveillance activities, supporting disease reduction strategies and removing barriers across the continuum of care, particularly for populations that are disproportionately impacted by the disease. Through the coordination of the Rhode Island Hepatitis C Action Coalition, the Rhode Island Department of Health (RIDOH), the Executive Office of Health and Human Services (EOHHS), community organizations, and clinical leaders, important steps have been taken to reduce transmission of the disease and work toward HCV elimination.

The process of obtaining informed consent to research in long term care facilities (LTCFs): An Observational Clinical Study

We examined the process of obtaining informed consent (IC) for clinical research purposes in long-term care facilities (LTCFs) in Rhode Island (RI), USA. We assessed factors that were associated with resident ability to consent, such as Brief Interview for Mental Status scores. We used a self-administered questionnaire to further understand the effect of LTCF staff evaluation of ability to consent on residents' autonomy and control over their medical decision making.Observational clinical studyLong-term care setting.LTCF personnel provided us with residents' names, as well as their professional assessment of resident ability to consent. We used Brief Interview for Mental Status (BIMS) scores to assess the cognitive capacity of all residents to assess, and compare it to the assessment provided by LTCF personnel. A logistic regression analysis was performed to determine the relationship between LTCF assessment of resident ability to consent and BIMS score or confirmed diagnosis of dementia as seen from residents' medical charts. A self-administered questionnaire was filled out by the personnel of 10 LTCFs across RI, USA.LTCF personnel in 9 out of 10 recruited facilities reported that their assessment of resident ability to consent was based on subjective assessment of the resident as alert and oriented. There was a statistically significant relationship between the LTCF assessment of resident ability to consent and previously diagnosed dementia (OR: 0.211, 95% CI 0.107-0.415). Therefore, as BIMS scores increased, the likelihood that the resident would be deemed able to consent by LTCF personnel also increased. Furthermore, there was a statistically significant relationship between LTCF assessment of resident ability to consent and BIMS scores (OR: 1.430, 95% CI 1.274-1.605).There is no standard on obtaining IC for research studies conducted in LTCFs. We recommend that standardizing the process of obtaining IC in LTCFs can enhance the ability to perform research with LTCF residents.

Comparison of Common Respiratory Virus Peak Incidence Among Varying Age Groups in Rhode Island, 2012-2016

This case series study assesses the seasonality of respiratory viral infections among different age groups in Rhode Island from 2012 to 2016.

Preconception Marijuana Use in Rhode Island: Rates, Demographics, and Psychosocial Correlates

INTRODUCTION

Rates of marijuana use in Rhode Island (RI) exceed the national average; prevalence during preconception and characteristics of users remain unknown.

METHODS

Prevalence of marijuana use in the 3 months preconception was assessed by a RI-based telephone survey of a diverse, low-income sample of pregnant women (n=1683). Sociodemographic characteristics, substance use, and mental health were compared between preconception marijuana users, tobacco users and non-users.

RESULTS

25.1% of respondents reported using marijuana during preconception. Marijuana users were younger, poorer, and less educated than non-users (ps<0.001) and more likely to report alcohol use and mental illness (ps<0.001). Marijuana users were younger with fewer children than tobacco-only users (ps<0.001).

CONCLUSIONS

Rates of preconception marijuana use in RI exceed national rates of prenatal use. Preconception marijuana users have a distinct sociodemographic profile, with higher rates of concurrent mental health conditions and alcohol use. Understanding this characterization enables targeted screening and interventions.

Prescription Opioid Prescribing in Western Europe and the United States

Pain is universal, yet the prevalence of overdose and treatment of pain varies significantly between the United States (US) and Western Europe. Overdose deaths are seven times more common in the US compared to Western Europe. Cultural perceptions of pain, perception and treatment of opioid use disorder, pharmaceutical advertising, and rates and regulation of prescribing of opioids represent examples of factors that may be related to such differences between the US and Western Europe. As Rhode Island continues to battle the devastating and well-documented national opioid overdose epidemic, we should consider how cultural, regulatory differences, and economic factors may influence pain and its treatment.

Safety and Nosocomial Clostridioides difficile Infections

The rate of nosocomial C. difficile in the state of Rhode Island is among the highest in the country. Multiple factors impact the occurrence of nosocomial C. difficile. Improvement in a single factor may not lead to a decrease in the rate. We report the results of a multidisciplinary team that implemented multiple interventions, which led to a 42% reduction of nosocomial C. difficile at The Miriam Hospital.

Antibiotics and Nosocomial Clostridioides difficile, a Retrospective Chart Review

C. difficile is a complication of antibiotic therapy. Certain antibiotics are associated with a higher rate of developing C. difficile. The charts of 54 patients with nosocomial C. difficile were reviewed and very few had received a high-risk antibiotic. Seven (13%) of 54 patients had not received any antibiotics in the hospital prior to the positive stool test for C. difficile. Moreover, 6 of the 7 had no documentation of receiving an antibiotic in the 56 days prior to admission suggesting that they might be colonized with C. difficile.

Mapping the Opioid Epidemic in Rhode Island: Where Are We Missing Resources?

Opioid overdose deaths have been rising steadily over the past decade in Rhode Island (RI), and although deaths have decreased slightly over the past year, there were 314 deaths in 2018 and there have been 208 deaths in the first 9 months of 2019.1 The objective of this spatial study is to identify the RI regions with the greatest need for opioid emergency response and rehabilitation resources. Using geographic information systems (GIS), we identify areas in RI with high overdose rates and that are far from emergency departments, and areas with high rates of treatment admissions that are far away from Centers of Excellence (COEs) which provide effective medication-assisted treatment (MAT). Ultimately, we identified Burrillville, Coventry, Bristol, and Portsmouth as towns needing more emergency resources and Western Hopkinton, Western Richmond, and Western Scituate as areas needing more high-quality rehabilitation resources. These findings should inform future decisions when considering new locations for COEs or emergency resources to respond to the Rhode Island opioid epidemic.

Predicting high-risk opioid prescriptions before they are given

Misuse of prescription opioids is a leading cause of premature death in the United States. We use state government administrative data and machine learning methods to examine whether the risk of future opioid dependence, abuse, or poisoning can be predicted in advance of an initial opioid prescription. Our models accurately predict these outcomes and identify particular prior nonopioid prescriptions, medical history, incarceration, and demographics as strong predictors. Using our estimates, we simulate a hypothetical policy which restricts new opioid prescriptions to only those with low predicted risk. The policy's potential benefits likely outweigh costs across demographic subgroups, even for lenient definitions of "high risk." Our findings suggest new avenues for prevention using state administrative data, which could aid providers in making better, data-informed decisions when weighing the medical benefits of opioid therapy against the risks.

A pilot study to examine the acceptability and health effects of electronic cigarettes in HIV-positive smokers

INTRODUCTION

Some HIV-positive smokers report ambivalence about quitting. Switching to electronic cigarettes (ECs) may be a viable option to reduce the negative health effects for smokers who are unable or unwilling to quit smoking combustible cigarettes (CCs). This study examined the acceptability and health-related effects of ECs in HIV-positive smokers who were not seeking smoking cessation treatment.

METHODS

HIV-positive smokers (N = 19) were enrolled and followed for 12 weeks. Cartridge-based ECs were provided at baseline, and E-liquid was provided weekly for 8 weeks. At baseline, weeks 1-8, and week 12, EC and CC use, cardiopulmonary function, respiratory symptoms, and carbon monoxide (CO) levels were measured.

RESULTS

At week 8, cigarettes per day (CPD) were reduced by more than 80%, with reduction maintained at week 12 (p's < .001). Cigarette dependence scores were 40% lower at week 8 than at baseline (p <  .001). Seven (36.8%) participants reported transitioning completely from CCs to ECs. Mean CO decreased significantly from BL to week 8 (p < .05) and remained significantly lower at week 12 (p <  .001). Intention to quit increased significantly over time.

CONCLUSIONS

Switching from CCs to ECs in HIV-positive smokers who are not ready to quit smoking in the next 30 days appears to be feasible. Beneficial effects were seen, such as reduced CPD, reduced CO and CC dependence, and increased motivation to quit. ECs may be promising as a harm reduction approach among HIV-positive smokers who are unable or unwilling to quit smoking.