The aim of the study was to determine the main factors contributing to hospital readmissions and their potential preventability after a coronavirus disease 2019 (COVID-19) hospitalization at 2 New York City hospitals.Methods: This was a retrospective study at 2 affiliated New York City hospitals located in the Upper East Side and Lower Manhattan neighborhoods. We performed case reviews using the Hospital Medicine Reengineering Network framework to determine potentially preventable readmissions among patients hospitalized for COVID-19 between March 3, 2020 (date of first case) and April 27, 2020, and readmitted to either of the 2 hospitals within 30 days of discharge.Results: Among 53 readmissions after hospitalization for COVID-19, 44 (83%) were deemed not preventable and 9 (17%) were potentially preventable. Nonpreventable readmissions were mostly due to disease progression or complications of COVID-19 (37/44, 84%). Main factors contributing to potentially preventable readmissions were issues with initial disposition (5/ 9, 56%), premature discharge (3/9, 33%), and inappropriate readmission (1/9, 11%) for someone who likely did not require rehospitalization. Conclusions:Most readmissions after a COVID-19 hospitalization were not preventable and a consequence of the natural progression of the disease, specifically worsening dyspnea or hypoxemia. Some readmissions were potentially preventable, mostly because of issues with disposition that were directly related to challenges posed by the ongoing COVID-19 pandemic. Clinicians should be aware of challenges with disposition related to circumstances of the COVID-19 pandemic.

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Introduction: Probiotics are live microorganisms that, when consumed in sufficient quantity, are intended to confer a health benefit. According to the NIH, probiotics are the third most used dietary supplement in the United States, with most formulations containing bacteria of the Lactobacillus genus. Despite limited clinical evidence and unclear mechanism of action, probiotics are commonly used to promote or restore the intestinal microbial balance of both healthy and ill patients. Due to significant dysbiosis in patients with inflammatory bowel disease, there has been a growing interest in the prophylactic and therapeutic potential of probiotic use. Case Description/Methods: Our case describes a 69 year-old male presenting with 1-week of fevers, fatigue, and arthralgias shortly after a 2.5-month course of corticosteroids and intermittent levofloxacin treatments. His medical history included bioprosthetic aortic valve replacement 2-years prior and ulcerative colitis taking daily balsalazide and lactobacillus-containing probiotics. On presentation the patient met 3 of 4 SIRS criteria for shock with suspected infectious etiology. Empiric IV antibiotics and fluid resuscitation was initiated, with vasopressors added for persistent hypotension. Blood cultures revealed Lactobacillus rhamnosus bacteremia at 31 hours and antibiotics were deescalated to IV ampicillin. Four days after hospital discharge the patient experienced acute right-sided paresthesia and paresis. Upon return to the emergency room, magnetic resonance imaging of the brain demonstrated numerous ring-enhancing lesions with hemorrhagic transformation. Transesophageal echocardiogram revealed a new mobile density on the bioprosthetic aortic valve, raising the suspicion for Lactobacilli rhamnosus infective endocarditis with secondary septic emboli to the brain. The patient was subsequently treated with IV gentamycin and ampicillin, with transition to indefinite oral amoxicillin suppressive therapy. Discussion: Considered non-pathogenic flora, studies have shown Lactobacilli to be the most common bacteria to translocate the intestine. Nevertheless, opportunistic infections in healthy individuals are rare owing to an intact intestinal barrier and rapid immune clearance of translocated bacteria. The present case highlights the increased literature-reported risk of Lactobacillus translocation in patients who are immunocompromised, use microbiome-disrupting antibiotics, or suffer from disorders associated with increased intestinal barrier permeability.[2702] Figure 1. Contrast enhanced magnetic resonance imaging (MRI) of the brain. (A-B) Demonstrates supratentorial ring-enhancing lesions involving the left parietal and left occipital regions (green arrows). (C) Susceptibility weighted imaging (SWI) shows evidence of hemorrhage (red arrow) within lesions, with greatest hemorrhage involving the left middle frontal gyrus.

Background Controversy exists for ustekinumab concentrations needed in Crohn’s disease (CD). No data exist comparing ustekinumab concentrations and validated radiologic outcomes. We characterized these relationships and clarified concentrations needed. Methods CD patients on maintenance (> 16 weeks) ustekinumab with both ustekinumab concentrations and simplified magnetic resonance index of activity (sMaRIA) scoring were included. Ustekinumab concentrations were compared between those with and without (1) radiologic remission (sMaRIA < 2), (2) severe radiologic inflammation (sMaRIA < 3) and (3) fecal calprotectin (FCP) biomarker remission (FCP < 50μg/g). Area under the receiver-operating characteristic (AUROC) curve determined optimal ustekinumab concentrations. Outcomes were compared between patients above and below identified ustekinumab thresholds. Results Thirty-eight paired ustekinumab concentrations and magnetic resonance enterography imaging results were included. Ustekinumab concentrations were higher with radiologic remission (11.4μg/mL vs. 6.4μg/mL, P=.005) and had good diagnostic accuracy for radiologic remission (AUROC 0.76, 95% CI 0.60 – 0.91) and for absence of severe inflammation (AUROC 0.71, 95% CI 0.55 – 0.88, optimal concentration 8.4μg/mL). With ustekinumab ≥8.4μg/mL, higher proportions had radiologic remission (63.2% vs. 21.1%, P=.01) and absence of severe inflammation (78.9% vs. 36.8%, P=.01) compared to patients with lower concentrations. Ustekinumab concentrations had good diagnostic accuracy (AUROC 0.73, 95% CI 0.52 – 0.94) for FCP biomarker remission (optimal concentration: 6.1μg/mL). Patients with ustekinumab concentrations ≥6.1μg/mL had higher proportions with biomarker remission (72.2% vs. 12.5% P<.01) compared to those with lower concentrations. Conclusion Ustekinumab concentrations are associated with radiologic and biomarker outcomes in CD. These data validate the need for higher ustekinumab concentrations.

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