Clinical Focus


  • Critical Care
  • Critical Care Medicine

Academic Appointments


Professional Education


  • Board Certification: American Board of Emergency Medicine, Critical Care Medicine (2021)
  • Fellowship: Stanford University Critical Care Medicine Fellowship (2020) CA
  • Board Certification: American Board of Emergency Medicine, Emergency Medicine (2019)
  • Residency: Stanford University Emergency Medicine Residency (2018) CA
  • Medical Education: University of Illinois College of Medicine Office of the Registrar (2015) IL

All Publications


  • External validation of the 4C Mortality Score for hospitalised patients with COVID-19 in the RECOVER network. BMJ open Gordon, A. J., Govindarajan, P., Bennett, C. L., Matheson, L., Kohn, M. A., Camargo, C., Kline, J. 2022; 12 (4): e054700

    Abstract

    Estimating mortality risk in hospitalised SARS-CoV-2+ patients may help with choosing level of care and discussions with patients. The Coronavirus Clinical Characterisation Consortium Mortality Score (4C Score) is a promising COVID-19 mortality risk model. We examined the association of risk factors with 30-day mortality in hospitalised, full-code SARS-CoV-2+ patients and investigated the discrimination and calibration of the 4C Score. This was a retrospective cohort study of SARS-CoV-2+ hospitalised patients within the RECOVER (REgistry of suspected COVID-19 in EmeRgency care) network.99 emergency departments (EDs) across the USA.Patients ≥18 years old, positive for SARS-CoV-2 in the ED, and hospitalised.Death within 30 days of the index visit. We performed logistic regression analysis, reporting multivariable risk ratios (MVRRs) and calculated the area under the ROC curve (AUROC) and mean prediction error for the original 4C Score and after dropping the C reactive protein (CRP) component.Of 6802 hospitalised patients with COVID-19, 1149 (16.9%) died within 30 days. The 30-day mortality was increased with age 80+ years (MVRR=5.79, 95% CI 4.23 to 7.34); male sex (MVRR=1.17, 1.05 to 1.28); and nursing home/assisted living facility residence (MVRR=1.29, 1.1 to 1.48). The 4C Score had comparable discrimination in the RECOVER dataset compared with the original 4C validation dataset (AUROC: RECOVER 0.786 (95% CI 0.773 to 0.799), 4C validation 0.763 (95% CI 0.757 to 0.769). Score-specific mortalities in our sample were lower than in the 4C validation sample (mean prediction error 6.0%). Dropping the CRP component from the 4C Score did not substantially affect discrimination and 4C risk estimates were now close (mean prediction error 0.7%).We independently validated 4C Score as predicting risk of 30-day mortality in hospitalised SARS-CoV-2+ patients. We recommend dropping the CRP component of the score and using our recalibrated mortality risk estimates.

    View details for DOI 10.1136/bmjopen-2021-054700

    View details for PubMedID 35450898

  • Selection bias in estimating the relationship between prolonged ED boarding and mortality in emergency critical care patients. Journal of the American College of Emergency Physicians open Gardner, K., Gordon, A. J., Shannon, B., Nesbitt, J., Wilson, J. G., Mitarai, T., Kohn, M. A. 2022; 3 (1): e12667

    Abstract

    Objectives: Studies have found that prolonged boarding time for intensive care unit (ICU) patients in the emergency department (ED) is associated with higher in-hospital mortality. However, these studies introduced selection bias by excluding patients with ICU admission orders who were downgraded and never arrived in the ICU. Consequently, they may overestimate mortality in prolonged ED boarders.Methods: This was a retrospective cohort study at a single center covering the period from August 14, 2015 to August 13, 2019. Adult ED patients with medical ICU admission orders and at least 6hours of subsequent critical care in either the ED or the ICU were included. Patients were classified as having either prolonged(>6hours) or non-prolonged (≤6hours) ED boarding. Downgraded patients were identified, and mortality was compared, both including and excluding downgraded patients.Results: Of 1862 patients, 612 (32.9%) had prolonged boarding; at 6hours after ICU admission order entry, they were still in the ED. The remaining 1250 (67.1%) had non-prolonged boarding; at 6hours after the ICU admission order entry, they were already in the ICU. In-hospital mortality in the non-prolonged boarding group was 18.9%. In the prolonged boarding group, 296 (48.4%) patients were downgraded in the ED and never arrived in the ICU. Including these ED downgrades, the mortality in the prolonged boarding group was 13.4% (risk difference -5.5%, 95% confidence interval [CI] -8.9% to -2.0%, P=0.0031). When we excluded downgrades, the mortality in the prolonged boarding group increased to 17.4% (risk difference -1.5%, 95% CI -6.2% to 3.2%, P=0.5720). The lower mortality in the prolonged group was attributable to lower severity of illness (mean emergency critical care SOFA [eccSOFA] difference: -0.8, 95% CI -1.1 to -0.4, P<0.0001).Conclusions: Excluding critical care patients who were downgraded in the ED leads to selection bias and overestimation of mortality among prolonged ED boarders.

    View details for DOI 10.1002/emp2.12667

    View details for PubMedID 35128534

  • Effectiveness of a Third Dose of Pfizer-BioNTech and Moderna Vaccines in Preventing COVID-19 Hospitalization Among Immunocompetent and Immunocompromised Adults - United States, August-December 2021 MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT Tenforde, M. W., Patel, M. M., Gaglani, M., Ginde, A. A., Douin, D. J., Talbot, H., Casey, J. D., Mohr, N. M., Zepeski, A., McNeal, T., Ghamande, S., Gibbs, K. W., Files, D., Hager, D. N., Shehu, A., Prekker, M. E., Erickson, H. L., Gong, M. N., Mohamed, A., Johnson, N. J., Srinivasan, V., Steingrub, J. S., Peltan, I. D., Brown, S. M., Martin, E. T., Monto, A. S., Khan, A., Hough, C. L., Busse, L. W., Duggal, A., Wilson, J. G., Qadir, N., Chang, S. Y., Mallow, C., Rivas, C., Babcock, H. M., Kwon, J. H., Exline, M. C., Botros, M., Lauring, A. S., Shapiro, N., Halasa, N., Chappell, J. D., Grijalva, C. G., Rice, T. W., Jones, I. D., Stubblefield, W. B., Baughman, A., Womack, K. N., Rhoads, J. P., Lindsell, C. J., Hart, K. W., Zhu, Y., Naioti, E. A., Adams, K., Lewis, N. M., Surie, D., McMorrow, M. L., Self, W. H., IVY Network 2022; 71 (4): 118-124

    Abstract

    COVID-19 mRNA vaccines (BNT162b2 [Pfizer-BioNTech] and mRNA-1273 [Moderna]) provide protection against infection with SARS-CoV-2, the virus that causes COVID-19, and are highly effective against COVID-19-associated hospitalization among eligible persons who receive 2 doses (1,2). However, vaccine effectiveness (VE) among persons with immunocompromising conditions* is lower than that among immunocompetent persons (2), and VE declines after several months among all persons (3). On August 12, 2021, the Food and Drug Administration (FDA) issued an emergency use authorization (EUA) for a third mRNA vaccine dose as part of a primary series ≥28 days after dose 2 for persons aged ≥12 years with immunocompromising conditions, and, on November 19, 2021, as a booster dose for all adults aged ≥18 years at least 6 months after dose 2, changed to ≥5 months after dose 2 on January 3, 2022 (4,5,6). Among 2,952 adults (including 1,385 COVID-19 case-patients and 1,567 COVID-19-negative controls) hospitalized at 21 U.S. hospitals during August 19-December 15, 2021, effectiveness of mRNA vaccines against COVID-19-associated hospitalization was compared between adults eligible for but who had not received a third vaccine dose (1,251) and vaccine-eligible adults who received a third dose ≥7 days before illness onset (312). Among 1,875 adults without immunocompromising conditions (including 1,065 [57%] unvaccinated, 679 [36%] 2-dose recipients, and 131 [7%] 3-dose [booster] recipients), VE against COVID-19 hospitalization was higher among those who received a booster dose (97%; 95% CI = 95%-99%) compared with that among 2-dose recipients (82%; 95% CI = 77%-86%) (p <0.001). Among 1,077 adults with immunocompromising conditions (including 324 [30%] unvaccinated, 572 [53%] 2-dose recipients, and 181 [17%] 3-dose recipients), VE was higher among those who received a third dose to complete a primary series (88%; 95% CI = 81%-93%) compared with 2-dose recipients (69%; 95% CI = 57%-78%) (p <0.001). Administration of a third COVID-19 mRNA vaccine dose as part of a primary series among immunocompromised adults, or as a booster dose among immunocompetent adults, provides improved protection against COVID-19-associated hospitalization.

    View details for Web of Science ID 000748639100001

    View details for PubMedID 35085218

  • Clinical severity of, and effectiveness of mRNA vaccines against, covid-19 from omicron, delta, and alpha SARS-CoV-2 variants in the United States: prospective observational study. BMJ (Clinical research ed.) Lauring, A. S., Tenforde, M. W., Chappell, J. D., Gaglani, M., Ginde, A. A., McNeal, T., Ghamande, S., Douin, D. J., Talbot, H. K., Casey, J. D., Mohr, N. M., Zepeski, A., Shapiro, N. I., Gibbs, K. W., Files, D. C., Hager, D. N., Shehu, A., Prekker, M. E., Erickson, H. L., Exline, M. C., Gong, M. N., Mohamed, A., Johnson, N. J., Srinivasan, V., Steingrub, J. S., Peltan, I. D., Brown, S. M., Martin, E. T., Monto, A. S., Khan, A., Hough, C. L., Busse, L. W., Ten Lohuis, C. C., Duggal, A., Wilson, J. G., Gordon, A. J., Qadir, N., Chang, S. Y., Mallow, C., Rivas, C., Babcock, H. M., Kwon, J. H., Halasa, N., Grijalva, C. G., Rice, T. W., Stubblefield, W. B., Baughman, A., Womack, K. N., Rhoads, J. P., Lindsell, C. J., Hart, K. W., Zhu, Y., Adams, K., Schrag, S. J., Olson, S. M., Kobayashi, M., Verani, J. R., Patel, M. M., Self, W. H., Influenza and Other Viruses in the Acutely Ill (IVY) Network 2022; 376: e069761

    Abstract

    OBJECTIVES: To characterize the clinical severity of covid-19 associated with the alpha, delta, and omicron SARS-CoV-2 variants among adults admitted to hospital and to compare the effectiveness of mRNA vaccines to prevent hospital admissions related to each variant.DESIGN: Case-control study.SETTING: 21 hospitals across the United States.PARTICIPANTS: 11690 adults (≥18 years) admitted to hospital: 5728 with covid-19 (cases) and 5962 without covid-19 (controls). Patients were classified into SARS-CoV-2 variant groups based on viral whole genome sequencing, and, if sequencing did not reveal a lineage, by the predominant circulating variant at the time of hospital admission: alpha (11 March to 3 July 2021), delta (4 July to 25 December 2021), and omicron (26 December 2021 to 14 January 2022).MAIN OUTCOME MEASURES: Vaccine effectiveness calculated using a test negative design for mRNA vaccines to prevent covid-19 related hospital admissions by each variant (alpha, delta, omicron). Among patients admitted to hospital with covid-19, disease severity on the World Health Organization's clinical progression scale was compared among variants using proportional odds regression.RESULTS: Effectiveness of the mRNA vaccines to prevent covid-19 associated hospital admissions was 85% (95% confidence interval 82% to 88%) for two vaccine doses against the alpha variant, 85% (83% to 87%) for two doses against the delta variant, 94% (92% to 95%) for three doses against the delta variant, 65% (51% to 75%) for two doses against the omicron variant; and 86% (77% to 91%) for three doses against the omicron variant. In-hospital mortality was 7.6% (81/1060) for alpha, 12.2% (461/3788) for delta, and 7.1% (40/565) for omicron. Among unvaccinated patients with covid-19 admitted to hospital, severity on the WHO clinical progression scale was higher for the delta versus alpha variant (adjusted proportional odds ratio 1.28, 95% confidence interval 1.11 to 1.46), and lower for the omicron versus delta variant (0.61, 0.49 to 0.77). Compared with unvaccinated patients, severity was lower for vaccinated patients for each variant, including alpha (adjusted proportional odds ratio 0.33, 0.23 to 0.49), delta (0.44, 0.37 to 0.51), and omicron (0.61, 0.44 to 0.85).CONCLUSIONS: mRNA vaccines were found to be highly effective in preventing covid-19 associated hospital admissions related to the alpha, delta, and omicron variants, but three vaccine doses were required to achieve protection against omicron similar to the protection that two doses provided against the delta and alpha variants. Among adults admitted to hospital with covid-19, the omicron variant was associated with less severe disease than the delta variant but still resulted in substantial morbidity and mortality. Vaccinated patients admitted to hospital with covid-19 had significantly lower disease severity than unvaccinated patients for all the variants.

    View details for DOI 10.1136/bmj-2021-069761

    View details for PubMedID 35264324

  • Effectiveness of mRNA vaccines in preventing COVID-19 hospitalization by age and burden of chronic medical conditions among immunocompetent US adults, March-August 2021. The Journal of infectious diseases Lewis, N. M., Naioti, E. A., Self, W. H., Ginde, A. A., Douin, D. J., Talbot, H. K., Casey, J. D., Mohr, N. M., Zepeski, A., Gaglani, M., Ghamande, S. A., McNeal, T. A., Shapiro, N. I., Gibbs, K. W., Files, D. C., Hager, D. N., Shehu, A., Prekker, M. E., Erickson, H. L., Gong, M. N., Mohamed, A., Henning, D. J., Steingrub, J. S., Peltan, I. D., Brown, S. M., Martin, E. T., Hubel, K., Hough, C. L., Busse, L. W., Ten Lohuis, C. C., Duggal, A., Wilson, J. G., Gordon, A. J., Qadir, N., Chang, S. Y., Mallow, C., Rivas, C., Babcock, H. M., Kwon, J. H., Exline, M. C., Halasa, N., Chappell, J. D., Lauring, A. S., Grijalva, C. G., Rice, T. W., Rhoads, J. P., Stubblefield, W. B., Baughman, A., Womack, K. N., Lindsell, C. J., Hart, K. W., Zhu, Y., Schrag, S. J., Kobayashi, M., Verani, J. R., Patel, M. M., Tenforde, M. W. 1800

    Abstract

    In a multi-state network, vaccine effectiveness (VE) against COVID-19 hospitalizations was evaluated among immunocompetent adults (≥18-years) during March-August 2021 using a case-control design. Among 1669 hospitalized COVID-19 cases (11% fully vaccinated) and 1950 RT-PCR-negative controls (54% fully vaccinated), VE was higher at 96% (95% CI: 93-98%) among patients with no chronic medical conditions than patients with ≥3 categories of conditions (83% [95% CI: 76-88%]). VE was similar between those aged 18-64 years vs ≥65 years (p>0.05). Vaccine effectiveness against severe COVID-19 was very high among adults without chronic conditions and lessened with increasing burden of comorbidities.

    View details for DOI 10.1093/infdis/jiab619

    View details for PubMedID 34932114

  • Natural language processing of head CT reports to identify intracranial mass effect: CTIME algorithm. The American journal of emergency medicine Gordon, A. J., Banerjee, I., Block, J., Winstead-Derlega, C., Wilson, J. G., Mitarai, T., Jarrett, M., Sanyal, J., Rubin, D. L., Wintermark, M., Kohn, M. A. 2021; 51: 388-392

    Abstract

    BACKGROUND: The Mortality Probability Model (MPM) is used in research and quality improvement to adjust for severity of illness and can also inform triage decisions. However, a limitation for its automated use or application is that it includes the variable "intracranial mass effect" (IME), which requires human engagement with the electronic health record (EHR). We developed and tested a natural language processing (NLP) algorithm to identify IME from CT head reports.METHODS: We obtained initial CT head reports from adult patients who were admitted to the ICU from our ED between 10/2013 and 9/2016. Each head CT head report was labeled yes/no IME by at least two of five independent labelers. The reports were then randomly divided 80/20 into training and test sets. All reports were preprocessed to remove linguistic and style variability, and a dictionary was created to map similar common terms. We tested three vectorization strategies: Term Frequency-Inverse Document frequency (TF-IDF), Word2Vec, and Universal Sentence Encoder to convert the report text to a numerical vector. This vector served as the input to a classification-tree-based ensemble machine learning algorithm (XGBoost). After training, model performance was assessed in the test set using the area under the receiver operating characteristic curve (AUROC). We also divided the continuous range of scores into positive/inconclusive/negative categories for IME.RESULTS: Of the 1202 CT reports in the training set, 308 (25.6%) reports were manually labeled as "yes" for IME. Of the 355 reports in the test set, 108 (30.4%) were labeled as "yes" for IME. The TF-IDF vectorization strategy as an input for the XGBoost model had the best AUROC:-- 0.9625 (95% CI 0.9443-0.9807). TF-IDF score categories were defined and had the following likelihood ratios: "positive" (TF-IDF score>0.5) LR=24.59; "inconclusive" (TF-IDF 0.05-0.5) LR=0.99; and "negative" (TF-IDF<0.05) LR=0.05. 82% of reports were classified as either "positive" or "negative". In the test set, only 4 of 199 (2.0%) reports with a "negative" classification were false negatives and only 8 of 93 (8.6%) reports classified as "positive" were false positives.CONCLUSION: NLP can accurately identify IME from free-text reports of head CTs in approximately 80% of records, adequate to allow automatic calculation of MPM based on EHR data for many applications.

    View details for DOI 10.1016/j.ajem.2021.11.001

    View details for PubMedID 34839182

  • Association Between mRNA Vaccination and COVID-19 Hospitalization and Disease Severity. JAMA Tenforde, M. W., Self, W. H., Adams, K., Gaglani, M., Ginde, A. A., McNeal, T., Ghamande, S., Douin, D. J., Talbot, H. K., Casey, J. D., Mohr, N. M., Zepeski, A., Shapiro, N. I., Gibbs, K. W., Files, D. C., Hager, D. N., Shehu, A., Prekker, M. E., Erickson, H. L., Exline, M. C., Gong, M. N., Mohamed, A., Henning, D. J., Steingrub, J. S., Peltan, I. D., Brown, S. M., Martin, E. T., Monto, A. S., Khan, A., Hough, C. L., Busse, L. W., Ten Lohuis, C. C., Duggal, A., Wilson, J. G., Gordon, A. J., Qadir, N., Chang, S. Y., Mallow, C., Rivas, C., Babcock, H. M., Kwon, J. H., Halasa, N., Chappell, J. D., Lauring, A. S., Grijalva, C. G., Rice, T. W., Jones, I. D., Stubblefield, W. B., Baughman, A., Womack, K. N., Rhoads, J. P., Lindsell, C. J., Hart, K. W., Zhu, Y., Olson, S. M., Kobayashi, M., Verani, J. R., Patel, M. M., Influenza and Other Viruses in the Acutely Ill (IVY) Network 2021

    Abstract

    Importance: A comprehensive understanding of the benefits of COVID-19 vaccination requires consideration of disease attenuation, determined as whether people who develop COVID-19 despite vaccination have lower disease severity than unvaccinated people.Objective: To evaluate the association between vaccination with mRNA COVID-19 vaccines-mRNA-1273 (Moderna) and BNT162b2 (Pfizer-BioNTech)-and COVID-19 hospitalization, and, among patients hospitalized with COVID-19, the association with progression to critical disease.Design, Setting, and Participants: A US 21-site case-control analysis of 4513 adults hospitalized between March 11 and August 15, 2021, with 28-day outcome data on death and mechanical ventilation available for patients enrolled through July 14, 2021. Date of final follow-up was August 8, 2021.Exposures: COVID-19 vaccination.Main Outcomes and Measures: Associations were evaluated between prior vaccination and (1) hospitalization for COVID-19, in which case patients were those hospitalized for COVID-19 and control patients were those hospitalized for an alternative diagnosis; and (2) disease progression among patients hospitalized for COVID-19, in which cases and controls were COVID-19 patients with and without progression to death or mechanical ventilation, respectively. Associations were measured with multivariable logistic regression.Results: Among 4513 patients (median age, 59 years [IQR, 45-69]; 2202 [48.8%] women; 23.0% non-Hispanic Black individuals, 15.9% Hispanic individuals, and 20.1% with an immunocompromising condition), 1983 were case patients with COVID-19 and 2530 were controls without COVID-19. Unvaccinated patients accounted for 84.2% (1669/1983) of COVID-19 hospitalizations. Hospitalization for COVID-19 was significantly associated with decreased likelihood of vaccination (cases, 15.8%; controls, 54.8%; adjusted OR, 0.15; 95% CI, 0.13-0.18), including for sequenced SARS-CoV-2 Alpha (8.7% vs 51.7%; aOR, 0.10; 95% CI, 0.06-0.16) and Delta variants (21.9% vs 61.8%; aOR, 0.14; 95% CI, 0.10-0.21). This association was stronger for immunocompetent patients (11.2% vs 53.5%; aOR, 0.10; 95% CI, 0.09-0.13) than immunocompromised patients (40.1% vs 58.8%; aOR, 0.49; 95% CI, 0.35-0.69) (P<.001) and weaker at more than 120 days since vaccination with BNT162b2 (5.8% vs 11.5%; aOR, 0.36; 95% CI, 0.27-0.49) than with mRNA-1273 (1.9% vs 8.3%; aOR, 0.15; 95% CI, 0.09-0.23) (P<.001). Among 1197 patients hospitalized with COVID-19, death or invasive mechanical ventilation by day 28 was associated with decreased likelihood of vaccination (12.0% vs 24.7%; aOR, 0.33; 95% CI, 0.19-0.58).Conclusions and Relevance: Vaccination with an mRNA COVID-19 vaccine was significantly less likely among patients with COVID-19 hospitalization and disease progression to death or mechanical ventilation. These findings are consistent with risk reduction among vaccine breakthrough infections compared with absence of vaccination.

    View details for DOI 10.1001/jama.2021.19499

    View details for PubMedID 34734975

  • Comparative Effectiveness of Moderna, Pfizer-BioNTech, and Janssen (Johnson & Johnson) Vaccines in Preventing COVID-19 Hospitalizations Among Adults Without Immunocompromising Conditions - United States, March-August 2021 MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT Self, W. H., Tenforde, M. W., Rhoads, J. P., Gaglani, M., Ginde, A. A., Douin, D. J., Olson, S. M., Talbot, K., Casey, J. D., Mohr, N. M., Zepeski, A., McNeal, T., Ghamande, S., Gibbs, K. W., Files, D., Hager, D. N., Shchu, A., Prekker, M. E., Erickson, H. L., Gong, M. N., Mohamed, A., Henning, D. J., Steingrub, J. S., Peltan, I. D., ten Lohuis, C. C., Duggal, A., Wilson, J. G., Gordon, A., Qadir, N., Chang, S. Y., Mallow, C., Rivas, C., Babcock, H. M., Kwon, J. H., Exline, M. C., Halasa, N., Chappell, J. D., Lauring, A. S., Grijalva, C. G., Rice, T. W., Jones, I. D., Stubblefield, W. B., Baughman, A., Womack, K. N., Lindsell, C. J., Hart, K. W., Zhu, Y., Mills, L., Lester, S. N., Stumpf, M. M., Naioti, E. A., Kobayashi, M., Verani, J. R., Thornburg, N. J., Patel, M. M., Brown, S. M., Martin, E. T., Monto, A. S., Khan, A., Hough, C. L., Busse, L. W., IVY Network 2021; 70 (38): 1337-1343

    Abstract

    Three COVID-19 vaccines are authorized or approved for use among adults in the United States (1,2). Two 2-dose mRNA vaccines, mRNA-1273 from Moderna and BNT162b2 from Pfizer-BioNTech, received Emergency Use Authorization (EUA) by the Food and Drug Administration (FDA) in December 2020 for persons aged ≥18 years and aged ≥16 years, respectively. A 1-dose viral vector vaccine (Ad26.COV2 from Janssen [Johnson & Johnson]) received EUA in February 2021 for persons aged ≥18 years (3). The Pfizer-BioNTech vaccine received FDA approval for persons aged ≥16 years on August 23, 2021 (4). Current guidelines from FDA and CDC recommend vaccination of eligible persons with one of these three products, without preference for any specific vaccine (4,5). To assess vaccine effectiveness (VE) of these three products in preventing COVID-19 hospitalization, CDC and collaborators conducted a case-control analysis among 3,689 adults aged ≥18 years who were hospitalized at 21 U.S. hospitals across 18 states during March 11-August 15, 2021. An additional analysis compared serum antibody levels (anti-spike immunoglobulin G [IgG] and anti-receptor binding domain [RBD] IgG) to SARS-CoV-2, the virus that causes COVID-19, among 100 healthy volunteers enrolled at three hospitals 2-6 weeks after full vaccination with the Moderna, Pfizer-BioNTech, or Janssen COVID-19 vaccine. Patients with immunocompromising conditions were excluded. VE against COVID-19 hospitalizations was higher for the Moderna vaccine (93%; 95% confidence interval [CI] = 91%-95%) than for the Pfizer-BioNTech vaccine (88%; 95% CI = 85%-91%) (p = 0.011); VE for both mRNA vaccines was higher than that for the Janssen vaccine (71%; 95% CI = 56%-81%) (all p<0.001). Protection for the Pfizer-BioNTech vaccine declined 4 months after vaccination. Postvaccination anti-spike IgG and anti-RBD IgG levels were significantly lower in persons vaccinated with the Janssen vaccine than the Moderna or Pfizer-BioNTech vaccines. Although these real-world data suggest some variation in levels of protection by vaccine, all FDA-approved or authorized COVID-19 vaccines provide substantial protection against COVID-19 hospitalization.

    View details for Web of Science ID 000701940200005

    View details for PubMedID 34555004

    View details for PubMedCentralID PMC8459899

  • Point-of-Care Ultrasound Predicts Clinical Outcomes in Patients With COVID-19. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine Kumar, A., Weng, I., Graglia, S., Lew, T., Gandhi, K., Lalani, F., Chia, D., Duanmu, Y., Jensen, T., Lobo, V., Nahn, J., Iverson, N., Rosenthal, M., Gordon, A. J., Kugler, J. 2021

    Abstract

    OBJECTIVES: Point-of-care ultrasound (POCUS) detects the pulmonary manifestations of COVID-19 and may predict patient outcomes.METHODS: We conducted a prospective cohort study at four hospitals from March 2020 to January 2021 to evaluate lung POCUS and clinical outcomes of COVID-19. Inclusion criteria included adult patients hospitalized for COVID-19 who received lung POCUS with a 12-zone protocol. Each image was interpreted by two reviewers blinded to clinical outcomes. Our primary outcome was the need for intensive care unit (ICU) admission versus no ICU admission. Secondary outcomes included intubation and supplemental oxygen usage.RESULTS: N=160 patients were included. Among critically ill patients, B-lines (94 vs 76%; P<.01) and consolidations (70 vs 46%; P<.01) were more common. For scans collected within 24hours of admission (N=101 patients), early B-lines (odds ratio [OR] 4.41 [95% confidence interval, CI: 1.71-14.30]; P<.01) or consolidations (OR 2.49 [95% CI: 1.35-4.86]; P<.01) were predictive of ICU admission. Early consolidations were associated with oxygen usage after discharge (OR 2.16 [95% CI: 1.01-4.70]; P=.047). Patients with a normal scan within 24hours of admission were less likely to require ICU admission (OR 0.28 [95% CI: 0.09-0.75]; P<.01) or supplemental oxygen (OR 0.26 [95% CI: 0.11-0.61]; P<.01). Ultrasound findings did not dynamically change over a 28-day scanning window after symptom onset.CONCLUSIONS: Lung POCUS findings detected within 24hours of admission may provide expedient risk stratification for important COVID-19 clinical outcomes, including future ICU admission or need for supplemental oxygen. Conversely, a normal scan within 24hours of admission appears protective. POCUS findings appeared stable over a 28-day scanning window, suggesting that these findings, regardless of their timing, may have clinical implications.

    View details for DOI 10.1002/jum.15818

    View details for PubMedID 34468039

  • Sustained Effectiveness of Pfizer-BioNTech and Moderna Vaccines Against COVID-19 Associated Hospitalizations Among Adults - United States, March-July 2021 MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT Tenforde, M. W., Self, W. H., Naioti, E. A., Ginde, A. A., Douin, D. J., Olson, S. M., Talbot, H., Casey, J. D., Mohr, N. M., Zepeski, A., Gaglani, M., McNeal, T., Ghamande, S., Shapiro, N. I., Gibbs, K. W., Files, D., Hager, D. N., Shehu, A., Prekker, M. E., Erickson, H. L., Gong, M. N., Mohamed, A., Henning, D. J., Steingrub, J. S., Peltan, I. D., Brown, S. M., Martin, E. T., Monto, A. S., Khan, A., Hough, C. L., Busse, L. W., ten Lohuis, C. C., Duggal, A., Wilson, J. G., Gordon, A., Qadir, N., Chang, S. Y., Mallow, C., Rivas, C., Babcock, H. M., Kwon, J. H., Exline, M. C., Halasa, N., Chappell, J. D., Lauring, A. S., Grijalva, C. G., Rice, T. W., Jones, I. D., Stubblefield, W. B., Baughman, A., Womack, K. N., Lindsell, C. J., Hart, K. W., Zhu, Y., Stephenson, M., Schrag, S. J., Kobayashi, M., Verani, J. R., Patel, M. M., IVY Network Investigators 2021; 70 (34): 1156-1162

    Abstract

    Real-world evaluations have demonstrated high effectiveness of vaccines against COVID-19-associated hospitalizations (1-4) measured shortly after vaccination; longer follow-up is needed to assess durability of protection. In an evaluation at 21 hospitals in 18 states, the duration of mRNA vaccine (Pfizer-BioNTech or Moderna) effectiveness (VE) against COVID-19-associated hospitalizations was assessed among adults aged ≥18 years. Among 3,089 hospitalized adults (including 1,194 COVID-19 case-patients and 1,895 non-COVID-19 control-patients), the median age was 59 years, 48.7% were female, and 21.1% had an immunocompromising condition. Overall, 141 (11.8%) case-patients and 988 (52.1%) controls were fully vaccinated (defined as receipt of the second dose of Pfizer-BioNTech or Moderna mRNA COVID-19 vaccines ≥14 days before illness onset), with a median interval of 65 days (range = 14-166 days) after receipt of second dose. VE against COVID-19-associated hospitalization during the full surveillance period was 86% (95% confidence interval [CI] = 82%-88%) overall and 90% (95% CI = 87%-92%) among adults without immunocompromising conditions. VE against COVID-19- associated hospitalization was 86% (95% CI = 82%-90%) 2-12 weeks and 84% (95% CI = 77%-90%) 13-24 weeks from receipt of the second vaccine dose, with no significant change between these periods (p = 0.854). Whole genome sequencing of 454 case-patient specimens found that 242 (53.3%) belonged to the B.1.1.7 (Alpha) lineage and 74 (16.3%) to the B.1.617.2 (Delta) lineage. Effectiveness of mRNA vaccines against COVID-19-associated hospitalization was sustained over a 24-week period, including among groups at higher risk for severe COVID-19; ongoing monitoring is needed as new SARS-CoV-2 variants emerge. To reduce their risk for hospitalization, all eligible persons should be offered COVID-19 vaccination.

    View details for Web of Science ID 000691315200005

    View details for PubMedID 34437524

  • Effectiveness of SARS-CoV-2 mRNA Vaccines for Preventing Covid-19 Hospitalizations in the United States. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Tenforde, M. W., Patel, M. M., Ginde, A. A., Douin, D. J., Talbot, H. K., Casey, J. D., Mohr, N. M., Zepeski, A., Gaglani, M., McNeal, T., Ghamande, S., Shapiro, N. I., Gibbs, K. W., Files, D. C., Hager, D. N., Shehu, A., Prekker, M. E., Erickson, H. L., Exline, M. C., Gong, M. N., Mohamed, A., Henning, D. J., Peltan, I. D., Brown, S. M., Martin, E. T., Monto, A. S., Khan, A., Hough, C. T., Busse, L., Ten Lohuis, C. C., Duggal, A., Wilson, J. G., Gordon, A. J., Qadir, N., Chang, S. Y., Mallow, C., Gershengorn, H. B., Babcock, H. M., Kwon, J. H., Halasa, N., Chappell, J. D., Lauring, A. S., Grijalva, C. G., Rice, T. W., Jones, I. D., Stubblefield, W. B., Baughman, A., Womack, K. N., Lindsell, C. J., Hart, K. W., Zhu, Y., Olson, S. M., Stephenson, M., Schrag, S. J., Kobayashi, M., Verani, J. R., Self, W. H., Influenza and Other Viruses in the Acutely Ill (IVY) Network 2021

    Abstract

    BACKGROUND: As SARS-CoV-2 vaccination coverage increases in the United States (US), there is a need to understand the real-world effectiveness against severe Covid-19 and among people at increased risk for poor outcomes.METHODS: In a multicenter case-control analysis of US adults hospitalized March 11-May 5, 2021, we evaluated vaccine effectiveness to prevent Covid-19 hospitalizations by comparing odds of prior vaccination with an mRNA vaccine (Pfizer-BioNTech or Moderna) between cases hospitalized with Covid-19 and hospital-based controls who tested negative for SARS-CoV-2.RESULTS: Among 1212 participants, including 593 cases and 619 controls, median age was 58 years, 22.8% were Black, 13.9% were Hispanic, and 21.0% had immunosuppression. SARS-CoV-2 lineage B.1.1.7 (Alpha) was the most common variant (67.9% of viruses with lineage determined). Full vaccination (receipt of two vaccine doses ≥14 days before illness onset) had been received by 8.2% of cases and 36.4% of controls. Overall vaccine effectiveness was 87.1% (95% CI: 80.7 to 91.3%). Vaccine effectiveness was similar for Pfizer-BioNTech and Moderna vaccines, and highest in adults aged 18-49 years (97.4%; 95% CI: 79.3 to 99.7%). Among 45 patients with vaccine-breakthrough Covid hospitalizations, 44 (97.8%) were ≥50 years old and 20 (44.4%) had immunosuppression. Vaccine effectiveness was lower among patients with immunosuppression (62.9%; 95% CI: 20.8 to 82.6%) than without immunosuppression (91.3%; 95% CI: 85.6 to 94.8%).CONCLUSION: During March-May 2021, SARS-CoV-2 mRNA vaccines were highly effective for preventing Covid-19 hospitalizations among US adults. SARS-CoV-2 vaccination was beneficial for patients with immunosuppression, but effectiveness was lower in the immunosuppressed population.

    View details for DOI 10.1093/cid/ciab687

    View details for PubMedID 34358310

  • Effectiveness of Pfizer-BioNTech and Moderna Vaccines Against COVID-19 Among Hospitalized Adults Aged >= 65 Years - United States, January-March 2021 MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT Tenforde, M. W., Olson, S. M., Self, W. H., Talbot, H., Lindsell, C. J., Steingrub, J. S., Shapiro, N., Ginde, A. A., Douin, D. J., Prekker, M. E., Brown, S. M., Peltan, I. D., Gong, M. N., Mohamed, A., Khan, A., Aline, M. C., Files, D., Gibbs, K. W., Stubblefield, W. B., Casey, J. D., Rice, T. W., Grijalva, C. G., Hager, D. N., Shehu, A., Qadir, N., Chang, S. Y., Wilson, J. G., Gaglani, M., Murthy, K., Calhoun, N., Monto, A. S., Martin, E. T., Malani, A., Zimmerman, R. K., Silveira, F. P., Middleton, D. B., Zhu, Y., Wyatt, D., Stephenson, M., Baughman, A., Womack, K. N., Hart, K. W., Kobayashi, M., Verani, J. R., Patel, M. M., IVY Network, HAIVEN Invest 2021; 70 (18): 674–79

    Abstract

    Adults aged ≥65 years are at increased risk for severe outcomes from COVID-19 and were identified as a priority group to receive the first COVID-19 vaccines approved for use under an Emergency Use Authorization (EUA) in the United States (1-3). In an evaluation at 24 hospitals in 14 states,* the effectiveness of partial or full vaccination† with Pfizer-BioNTech or Moderna vaccines against COVID-19-associated hospitalization was assessed among adults aged ≥65 years. Among 417 hospitalized adults aged ≥65 years (including 187 case-patients and 230 controls), the median age was 73 years, 48% were female, 73% were non-Hispanic White, 17% were non-Hispanic Black, 6% were Hispanic, and 4% lived in a long-term care facility. Adjusted vaccine effectiveness (VE) against COVID-19-associated hospitalization among adults aged ≥65 years was estimated to be 94% (95% confidence interval [CI] = 49%-99%) for full vaccination and 64% (95% CI = 28%-82%) for partial vaccination. These findings are consistent with efficacy determined from clinical trials in the subgroup of adults aged ≥65 years (4,5). This multisite U.S. evaluation under real-world conditions suggests that vaccination provided protection against COVID-19-associated hospitalization among adults aged ≥65 years. Vaccination is a critical tool for reducing severe COVID-19 in groups at high risk.

    View details for Web of Science ID 000647643800003

    View details for PubMedID 33956782

  • Effectiveness of SARS-CoV-2 mRNA Vaccines for Preventing Covid-19 Hospitalizations in the United States. medRxiv : the preprint server for health sciences Tenforde, M. W., Patel, M. M., Ginde, A. A., Douin, D. J., Talbot, H. K., Casey, J. D., Mohr, N. M., Zepeski, A., Gaglani, M., McNeal, T., Ghamande, S., Shapiro, N. I., Gibbs, K. W., Files, D. C., Hager, D. N., Shehu, A., Prekker, M. E., Erickson, H. L., Exline, M. C., Gong, M. N., Mohamed, A., Henning, D. J., Steingrub, J. S., Peltan, I. D., Brown, S. M., Martin, E. T., Monto, A. S., Khan, A., Hough, C. T., Busse, L., Lohuis, C. C., Duggal, A., Wilson, J. G., Gordon, A. J., Qadir, N., Chang, S. Y., Mallow, C., Gershengorn, H. B., Babcock, H. M., Kwon, J. H., Halasa, N., Chappell, J. D., Lauring, A. S., Grijalva, C. G., Rice, T. W., Jones, I. D., Stubblefield, W. B., Baughman, A., Womack, K. N., Lindsell, C. J., Hart, K. W., Zhu, Y., Olson, S. M., Stephenson, M., Schrag, S. J., Kobayashi, M., Verani, J. R., Self, W. H. 2021

    Abstract

    As SARS-CoV-2 vaccination coverage increases in the United States (US), there is a need to understand the real-world effectiveness against severe Covid-19 and among people at increased risk for poor outcomes.In a multicenter case-control analysis of US adults hospitalized March 11 - May 5, 2021, we evaluated vaccine effectiveness to prevent Covid-19 hospitalizations by comparing odds of prior vaccination with an mRNA vaccine (Pfizer-BioNTech or Moderna) between cases hospitalized with Covid-19 and hospital-based controls who tested negative for SARS-CoV-2.Among 1210 participants, median age was 58 years, 22.8% were Black, 13.8% were Hispanic, and 20.6% had immunosuppression. SARS-CoV-2 lineage B.1.1.7 was most common variant (59.7% of sequenced viruses). Full vaccination (receipt of two vaccine doses ≥14 days before illness onset) had been received by 45/590 (7.6%) cases and 215/620 (34.7%) controls. Overall vaccine effectiveness was 86.9% (95% CI: 80.4 to 91.2%). Vaccine effectiveness was similar for Pfizer-BioNTech and Moderna vaccines, and highest in adults aged 18-49 years (97.3%; 95% CI: 78.9 to 99.7%). Among 45 patients with vaccine-breakthrough Covid hospitalizations, 44 (97.8%) were ≥50 years old and 20 (44.4%) had immunosuppression. Vaccine effectiveness was lower among patients with immunosuppression (59.2%; 95% CI: 11.9 to 81.1%) than without immunosuppression (91.3%; 95% CI: 85.5 to 94.7%).During March-May 2021, SARS-CoV-2 mRNA vaccines were highly effective for preventing Covid-19 hospitalizations among US adults. SARS-CoV-2 vaccination was beneficial for patients with immunosuppression, but effectiveness was lower in the immunosuppressed population.

    View details for DOI 10.1101/2021.07.08.21259776

    View details for PubMedID 34268515

    View details for PubMedCentralID PMC8282104

  • Critical Care Education Day: A Novel, Multidisciplinary, and Interactive Critical Care Education Session for Emergency Medicine Residents CUREUS Htet, N. N., Gordon, A., Mitarai, T. 2020; 12 (1)
  • Critical Care Education Day: A Novel, Multidisciplinary, and Interactive Critical Care Education Session for Emergency Medicine Residents. Cureus Htet, N. N., Gordon, A. J., Mitarai, T. 2020; 12 (1): e6785

    Abstract

    Critical care medicine (CCM) is central to emergency medicine (EM) resident education. We feel that the traditional lecture format is not the ideal way to teach EM critical care, which requires integration and prioritization of diagnostic workup and team-based resuscitation under time pressure. We describe a novel critical care education day where an interactive, practical, and multidisciplinary critical care educational experience was provided for EM residents using case-based small-group sessions and fast-paced simulation.

    View details for DOI 10.7759/cureus.6785

    View details for PubMedID 32140345

    View details for PubMedCentralID PMC7045984

  • eccSOFA: SOFA illness severity score adapted to predict in-hospital mortality in emergency critical care patients. The American journal of emergency medicine Niknam, K. n., Nesbitt, J. n., Mitarai, T. n., Nudelman, M. J., Gordon, A. J., Wilson, J. G., Kohn, M. A. 2020; 41: 145–51

    Abstract

    Boarding of ICU patients in the ED is increasing. Illness severity scores may help emergency physicians stratify risk to guide earlier transfer to the ICU and assess pre-ICU interventions by adjusting for baseline mortality risk. Most existing illness severity scores are based on data that is not available at the time of the hospital admission decision or cannot be extracted from the electronic health record (EHR). We adapted the SOFA score to create a new illness severity score (eccSOFA) that can be calculated at the time of ICU admission order entry in the ED using EHR data. We evaluated this score in a cohort of emergency critical care (ECC) patients at a single academic center over a period of 3 years.This was a retrospective cohort study using EHR data to assess predictive accuracy of eccSOFA for estimating in-hospital mortality risk. The patient population included all adult patients who had a critical care admission order entered while in the ED of an academic medical center between 10/24/2013 and 9/30/2016. eccSOFA's discriminatory ability for in-hospital mortality was assessed using ROC curves.Of the 3912 patients whose in-hospital mortality risk was estimated, 2260 (57.8%) were in the low-risk group (scores 0-3), 1203 (30.8%) in the intermediate-risk group (scores 4-7), and 449 (11.5%) in the high-risk group (scores 8+). In-hospital mortality for the low-, intermediate, and high-risk groups was 4.2% (95%CI: 3.4-5.1), 15.5% (95% CI 13.5-17.6), and 37.9% (95% CI 33.4-42.3) respectively. The AUROC was 0.78 (95%CI: 0.75-0.80) for the integer score and 0.75 (95% CI: 0.72-0.77) for the categorical eccSOFA.As a predictor of in-hospital mortality, eccSOFA can be calculated based on variables that are commonly available at the time of critical care admission order entry in the ED and has discriminatory ability that is comparable to other commonly used illness severity scores. Future studies should assess the calibration of our absolute risk predictions.

    View details for DOI 10.1016/j.ajem.2020.12.018

    View details for PubMedID 33453549

  • The Birth of a Return to work Policy for New Resident Parents in Emergency Medicine ACADEMIC EMERGENCY MEDICINE Gordon, A., Sebok-Syer, S. S., Dohn, A. M., Smith-Coggins, R., Wang, N., Williams, S. R., Gisondi, M. A. 2019; 26 (3): 317–26

    View details for DOI 10.1111/acem.13684

    View details for Web of Science ID 000461220000006

  • The Birth of a Return to Work Policy for New Resident Parents in Emergency Medicine. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Gordon, A. J., Sebok-Syer, S., Dohn, A. M., Smith-Coggins, R., Wang, N. E., Williams, S. R., Gisondi, M. A. 2019

    Abstract

    OBJECTIVE: With the rising number of female physicians, there will be more children than ever born in residency and the current system is inadequate to handle this increase in new resident parents. Residency is stressful and rigorous in isolation, let alone when pregnant or with a new child. Policies that ease these stressful transitions are generally either insufficient or do not exist. Therefore, we created a comprehensive Return to Work Policy for resident parents and piloted its implementation. Our policy aims to: 1) establish a clear, shared understanding of the regulatory and training requirements as they pertain to parental leave, 2) facilitate a smooth transition for new parents returning back to work, and 3) summarize the local and institutional resources available for both males and females during residency training.METHOD: In Fall 2017, a task force was convened to draft a Return to Work Policy for New Resident Parents. The task force included 9 key stakeholders (i.e., residents, faculty, and administration) at our institution and was made up of 3 Graduate Medical Education (GME) Program Directors, a Vice Chair of Education, a Designated Institutional Official (DIO), a Chief Resident, and 3 members of our academic department's Faculty Affairs Committee. The task force was selected because of individual expertise in gender equity issues, mentorship of resident parents, GME, and departmental administration.RESULTS: After development, the policy was piloted from November 2017 to June 2018. Our pilot implementation period included 7 new resident parents. All of these residents received schedules that met the return to work scheduling terms of our Return to Work Policy including no overnight shifts, no sick call, no more than 3 shifts in a row. Of equal importance, throughout our pilot, the emergency department schedules at all of our clinical sites remained fully staffed and our sick call pool was unaffected.CONCLUSION: Our Return to Work Policy for New Resident Parents provides a comprehensive guide to training requirements and family leave policies, an overview of available resources, and a scheduling framework that makes for a smooth transition back to clinical duties. This article is protected by copyright. All rights reserved.

    View details for PubMedID 30636353