New York City Health + Hospitals is the largest safety-net health care delivery system in the United States. Before the coronavirus disease 2019 (COVID-19) pandemic, NYC Health + Hospitals served more than one million patients annually, including the most vulnerable New Yorkers, while billing fewer than five hundred telehealth visits monthly. Once the pandemic struck, we established a strategy to allow us to continue to serve our existing patients while treating the surge of new patients. Starting in March 2020, we were able to transform the system using virtual care platforms through which we conducted almost eightythree thousand billable televisits in one month, as well as more than thirty thousand behavioral health encounters via telephone and video. Telehealth also enabled us to support patient-family communication, postdischarge follow-up, and palliative care for patients with COVID-19. Expanded Medicaid coverage and insurance reimbursement for telehealth played a pivotal role in this transformation. As we move to a new blend of virtual and in-person care, it is vital that the major regulatory and insurance changes undergirding our COVID-19 telehealth response be sustained to protect access for our most vulnerable patients.

Recurrence of hepatitis C virus (HCV) after orthotopic liver transplant (OLT) may be mild or may lead to progressive liver disease requiring retransplantation (re-OLT). Results of re-OLT for hepatitis C are not well known. We analyzed outcomes in 14 patients retransplanted for recurrent hepatitis C. All had evidence of recurrent hepatitis on multiple biopsies. Polymerase chain reaction (PCR) was performed in blood or tissue samples from 12 patients when recurrence was suspected; all 12 were positive for HCV-RNA. Explants showed chronic hepatitis with bridging necrosis in 3 patients, hepatitis with transition to cirrhosis in 2, hepatitis and cirrhosis in 3, and cirrhosis alone in 2. In 2 patients, in whom immunosuppression had been withheld for 4 to 6 weeks, there was also evidence of chronic rejection. Four died of sepsis perioperatively (median, 32.5 days; range, 9-59); pre-OLT, 3 of 4 had renal failure, and 1 had fever with no obvious source of infection. Ten patients did well early after OLT and were discharged. One patient was readmitted 6 weeks after discharge and died of cytomegalovirus (CMV) infection 127 days after re-OLT. One patient with concomitant vanishing bile duct syndrome, probably due to chronic rejection, developed recurrent hepatitis and died of progressive liver failure 161 days after re-OLT. Eight patients are well at a median of 926 days (range, 315-1930) after re-OLT. Three have evidence of mild recurrent hepatitis on liver biopsy, one is overweight with severe steatosis on biopsy, and four have no evidence of recurrent hepatitis. Retransplantation for hepatitis C should be considered a viable option for patients who develop end-stage hepatic dysfunction secondary to recurrent disease and should be performed before development of infectious complications and renal insufficiency.

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