Publications by authors named "Hannah Karpel"

8 Publications

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Post-Discharge Health Status and Symptoms in Patients with Severe COVID-19.

J Gen Intern Med 2021 03 14;36(3):738-745. Epub 2021 Jan 14.

Division of General Internal Medicine and Clinical Innovation, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA.

Background: Little is known about long-term recovery from severe COVID-19 disease. Here, we characterize overall health, physical health, and mental health of patients 1 month after discharge for severe COVID-19.

Methods: This was a prospective single health system observational cohort study of patients ≥ 18 years hospitalized with laboratory-confirmed COVID-19 disease who required at least 6 l of oxygen during admission, had intact baseline cognitive and functional status, and were discharged alive. Participants were enrolled between 30 and 40 days after discharge. Outcomes were elicited through validated survey instruments: the PROMIS® Dyspnea Characteristics and PROMIS® Global Health-10.

Results: A total of 161 patients (40.6% of eligible) were enrolled; 152 (38.3%) completed the survey. Median age was 62 years (interquartile range [IQR], 50-67); 57 (37%) were female. Overall, 113/152 (74%) participants reported shortness of breath within the prior week (median score 3 out of 10 [IQR 0-5]), vs 47/152 (31%) pre-COVID-19 infection (0, IQR 0-1), p < 0.001. Participants also rated their physical health and mental health as worse in their post-COVID state (43.8, standard deviation 9.3; mental health 47.3, SD 9.3) compared to their pre-COVID state, (54.3, SD 9.3; 54.3, SD 7.8, respectively), both p < 0.001. Physical and mental health means in the general US population are 50 (SD 10). A total of 52/148 (35.1%) patients without pre-COVID oxygen requirements needed home oxygen after hospital discharge; 20/148 (13.5%) reported still using oxygen at time of survey.

Conclusions: Patients with severe COVID-19 disease typically experience sequelae affecting their respiratory status, physical health, and mental health for at least several weeks after hospital discharge.
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http://dx.doi.org/10.1007/s11606-020-06338-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808113PMC
March 2021

Clinical Outcomes in Critically Ill Coronavirus Disease 2019 Patients: A Unique New York City Public Hospital Experience.

Crit Care Explor 2020 Aug 19;2(8):e0188. Epub 2020 Aug 19.

Division of Pulmonary, Critical Care and Sleep Medicine, New York University Grossman School of Medicine, New York City, NY.

To explore demographics, comorbidities, transfers, and mortality in critically ill patients with confirmed severe acute respiratory syndrome coronavirus 2.

Design: Retrospective cohort study.

Setting: Data were collected from a large tertiary care public hospital ICU that is part of the largest public healthcare network in the United States.

Patients: One-hundred thirty-seven adult (≥ 18 yr old) ICU patients admitted between March 10, 2020, and April 7, 2020, with follow-up collected through May 18, 2020.

Interventions: None.

Measurements: Demographic, clinical, laboratory, treatment, and outcome data extracted from electronic medical records.

Main Results: The majority of patients were male (99/137; 72.3%) and older than 50 years old (108/137; 78.9%). The most reported ethnicity and race were Hispanic (61/137; 44.5%) and Black (23/137; 16.7%). One-hundred six of 137 patients had at least one comorbidity (77.4%). One-hundred twenty-one of 137 (78.1%) required mechanical ventilation of whom 30 (24.8%) moved to tracheostomy and 46 of 137 (33.6%) required new onset renal replacement therapy. Eighty-two of 137 patients (59.9%) died after a median of 8 days (interquartile range 5-15 d) in the ICU. Male sex had a trend toward a higher hazard of death (hazard ratio, 2.1 [1.1-4.0]) in the multivariable Cox model.

Conclusions: We report a mortality rate of 59.9% in a predominantly Hispanic and Black patient population. A significant association between comorbidities and mortality was not found in multivariable regression, and further research is needed to study factors that impact mortality in critical coronavirus disease 2019 patients. We also describe how a public hospital developed innovative approaches to safely manage a large volume of interhospital transfers and admitted patients.
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http://dx.doi.org/10.1097/CCE.0000000000000188DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7437795PMC
August 2020

Post-discharge health status and symptoms in patients with severe COVID-19.

medRxiv 2020 Aug 14. Epub 2020 Aug 14.

Division of General Internal Medicine and Clinical Innovation, Department of Medicine, NYU Grossman School of Medicine, New York, NY.

Background: Little is known about long-term recovery from severe COVID-19 disease. Here, we characterize overall health, physical health and mental health of patients one month after discharge for severe COVID-19.

Methods: This was a prospective single health system observational cohort study of patients ≥18 years hospitalized with laboratory-confirmed COVID-19 disease who required at least 6 liters of oxygen during admission, had intact baseline cognitive and functional status and were discharged alive. Participants were enrolled between 30 and 40 days after discharge. Outcomes were elicited through validated survey instruments: the PROMIS Dyspnea Characteristics and PROMIS Global Health-10.

Results: A total of 161 patients (40.6% of eligible) were enrolled; 152 (38.3%) completed the survey. Median age was 62 years (interquartile range [IQR], 50-67); 57 (37%) were female. Overall, 113/152 (74%) participants reported shortness of breath within the prior week (median score 3 out of 10 [IQR 0-5]), vs. 47/152 (31%) pre-COVID-19 infection (0, IQR 0-1), p<0.001. Participants also rated their physical health and mental health as worse in their post-COVID state (43.8, standard deviation 9.3; mental health 47.3, SD 9.3) compared to their pre-COVID state, (54.3, SD 9.3; 54.3, SD 7.8, respectively), both p <0.001. A total of 52/148 (35.1%) patients without pre-COVID oxygen requirements needed home oxygen after hospital discharge; 20/148 (13.5%) reported still using oxygen at time of survey.

Conclusions: Patients with severe COVID-19 disease typically experience sequelae affecting their respiratory status, physical health and mental health for at least several weeks after hospital discharge.
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http://dx.doi.org/10.1101/2020.08.11.20172742DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7430618PMC
August 2020

Hypoferritinemia and iron deficiency in youth with pediatric acute-onset neuropsychiatric syndrome.

Pediatr Res 2020 Aug 3. Epub 2020 Aug 3.

Division of Allergy, Immunology, & Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA.

Background: Pediatric acute-onset neuropsychiatric syndrome (PANS) is an abrupt debilitating psychiatric illness. We anecdotally observed hypoferritinemia and iron deficiency in a subset of patients with PANS, prompting this study.

Methods: In this IRB-approved prospective cohort study, we included patients seen at the Stanford PANS Clinic who met study criteria. The prevalence of hypoferritinemia (using cut-offs of 7 ng/ml in children ≤ 15 years and 18 ng/ml in adolescents > 15 years) and iron deficiency was estimated. Differences in patients with and without hypoferritinemia during PANS flare were explored.

Results: Seventy-nine subjects (mean age of PANS onset of 8.7 years) met study criteria. Hypoferritinemia was observed in 27% and three quarters occurred during a PANS flare. Compared to patients without hypoferritinemia during PANS flare, patients with hypoferritinemia had worse global impairment, more comorbid inflammatory diseases, and exhibited a chronic course of PANS illness. The estimated prevalence of iron deficiency was 3-8% in the PANS cohort, 1.4-2.0-fold higher than in the age- and sex-matched U.S.

Population: More stringent ferritin level cut-offs than the comparison CDC dataset were used.

Conclusion: Hypoferritinemia and iron deficiency appear to be more common in PANS patients. More research is needed to confirm and understand this association.

Impact: Our study suggests hypoferritinemia and iron deficiency are more common in patients with pediatric acute-onset neuropsychiatric syndrome (PANS) than in the sex- and age-matched US population.Hypoferritinemia was commonly observed during a disease flare but not associated with dietary or demographic factors. In patients with PANS and iron deficiency, clinicians should consider possibility of inflammation as the cause especially if iron deficiency cannot be explained by diet and blood loss.Future research should include larger cohorts to corroborate our study findings and consider examining the iron dynamics on MRI brain imaging in order to better understand the pathophysiology of PANS.
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http://dx.doi.org/10.1038/s41390-020-1103-3DOI Listing
August 2020

The 2016 California policy to eliminate nonmedical vaccine exemptions and changes in vaccine coverage: An empirical policy analysis.

PLoS Med 2019 12 23;16(12):e1002994. Epub 2019 Dec 23.

Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America.

Background: Vaccine hesitancy, the reluctance or refusal to receive vaccination, is a growing public health problem in the United States and globally. State policies that eliminate nonmedical ("personal belief") exemptions to childhood vaccination requirements are controversial, and their effectiveness to improve vaccination coverage remains unclear given limited rigorous policy analysis. In 2016, a California policy (Senate Bill 277) eliminated nonmedical exemptions from school entry requirements. The objective of this study was to estimate the association between California's 2016 policy and changes in vaccine coverage.

Methods And Findings: We used a quasi-experimental state-level synthetic control analysis and a county-level difference-in-differences analysis to estimate the impact of the 2016 California policy on vaccination coverage and prevalence of exemptions to vaccine requirements (nonmedical and medical). We used publicly available state-level data from the US Centers for Disease Control and Prevention on coverage of measles, mumps, and rubella (MMR) vaccination, nonmedical exemption, and medical exemption in children entering kindergarten. We used county-level data individually requested from state departments of public health on overall vaccine coverage and exemptions. Based on data availability, we included state-level data for 45 states, including California, from 2011 to 2017 and county-level data for 17 states from 2010 to 2017. The prespecified primary study outcome was MMR vaccination in the state analysis and overall vaccine coverage in the county analysis. In the state-level synthetic control analysis, MMR coverage in California increased by 3.3% relative to its synthetic control in the postpolicy period (top 2 of 43 states evaluated in the placebo tests, top 5%), nonmedical exemptions decreased by 2.4% (top 2 of 43 states evaluated in the placebo tests, top 5%), and medical exemptions increased by 0.4% (top 1 of 44 states evaluated in the placebo tests, top 2%). In the county-level analysis, overall vaccination coverage increased by 4.3% (95% confidence interval [CI] 2.9%-5.8%, p < 0.001), nonmedical exemptions decreased by 3.9% (95% CI 2.4%-5.4%, p < 0.001), and medical exemptions increased by 2.4% (95% CI 2.0%-2.9%, p < 0.001). Changes in vaccination coverage across counties after the policy implementation from 2015 to 2017 ranged from -6% to 26%, with larger increases in coverage in counties with lower prepolicy vaccine coverage. Results were robust to alternative model specifications. The limitations of the study were the exclusion of a subset of US states from the analysis and the use of only 2 years of postpolicy data based on data availability.

Conclusions: In this study, implementation of the California policy that eliminated nonmedical childhood vaccine exemptions was associated with an estimated increase in vaccination coverage and a reduction in nonmedical exemptions at state and county levels. The observed increase in medical exemptions was offset by the larger reduction in nonmedical exemptions. The largest increases in vaccine coverage were observed in the most "high-risk" counties, meaning those with the lowest prepolicy vaccine coverage. Our findings suggest that government policies removing nonmedical exemptions can be effective at increasing vaccination coverage.
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http://dx.doi.org/10.1371/journal.pmed.1002994DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6927583PMC
December 2019

Corrigendum to "Psychotic symptoms in youth with Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) may reflect syndrome severity and heterogeneity" [J. Psychiatr. Res. 110 (2019) 93-102].

J Psychiatr Res 2019 Jun 18;113:45. Epub 2019 Mar 18.

Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States; Stanford Pediatric Acute-onset Neuropsychiatric Syndrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States.

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http://dx.doi.org/10.1016/j.jpsychires.2019.03.010DOI Listing
June 2019

Psychotic symptoms in youth with Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) may reflect syndrome severity and heterogeneity.

J Psychiatr Res 2019 03 14;110:93-102. Epub 2018 Nov 14.

Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States; Stanford Pediatric Acute-onset Neuropsychiatric Sydrome Clinic and Research Program at Lucile Packard Children's Hospital, Stanford University, Stanford, CA, United States.

Objective: In the clinical syndrome Pediatric Acute-onset Neuropsychiatric Syndrome (PANS), obsessive compulsive disorder (OCD) and/or food refusal symptoms have an abrupt-onset (over 48 h) coupled with at least two other specified neuropsychiatric symptoms. We aimed to characterize in detail for the first time, psychotic symptoms experienced by children with PANS as well as the impact of psychotic symptoms on disease severity and course of illness. We inform about the diagnosis of the clinical description: PANS and hope to improve evaluation, treatment, diagnostic validity and future investigation.

Methods: Retrospective review of 143 consecutive PANS clinic patient charts meeting inclusion criteria. The Caregiver Burden Inventory, Global Impairment Score, and Children's Global Assessment Scale were used to assess impairment.

Results: Visual and auditory hallucinations were each experienced by 36%, of which most (83%) were transient and complex (non-threatening voices or figures). 6.3% and 5.5% of patients experienced delusions and thought disorganization respectively. Those with psychotic symptoms showed statistically significant differences in disease impairment and caregiver burden. There were no differences in time to treatment access or length of illness.

Conclusions: Over 1/3 of children with PANS experienced transient hallucinations. They were more impaired than those without psychotic symptoms, but showed no differences in disease progression. This difference may point toward heterogeneity in PANS. When evaluating children with acute psychotic symptoms, clinicians should screen for abrupt-onset of a symptom cluster including OCD and/or food refusal, with neuropsychiatric symptoms (enuresis, handwriting changes, tics, hyperactivity, sleep disorder) before initiating treatment.
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http://dx.doi.org/10.1016/j.jpsychires.2018.11.013DOI Listing
March 2019

Health Education for Women and Children: A Community-Engaged Mutual Learning Curriculum for Health Trainees.

MedEdPORTAL 2016 Nov 3;12:10492. Epub 2016 Nov 3.

Instructor, Research Associate, and Program Director, Division of General Pediatrics, Department of Pediatrics, Stanford University School of Medicine.

Introduction: Intimate partner violence (IPV) affects the physical and psychological health of survivors and their children; however, to our knowledge, no comprehensive health curriculum exists for this population. As a partnership between a transitional housing program (THP) and an academic medical center, we developed a health education curriculum for female IPV survivors using the principles of community-based participatory research (CBPR).

Methods: After partnering with a community-based organization, and recruiting participants (IPV survivors), the curriculum is then taught by health trainees. The materials needed to facilitate the 10 workshops are provided and include: a facilitator's guide; workshop materials, including PowerPoint slides and handouts; a training guide for a community partner to teach facilitators about IPV; a sample focus group guide for curricular evaluation that aligns with CBPR methodologies; a sample time line for curricular implementation; and CBPR resources.

Results: The curriculum was implemented for two 9-month periods between September 2014 and June 2016. During the first session, 80% of women attended at least one workshop and during the second session, 65% of women did the same. Participants and staff at the THP found the curriculum engaging and requested that it be implemented yearly.

Discussion: The community-academic partnership offered prehealth and health trainees the opportunity to learn effective methods of delivering health education and to understand some of the challenges associated with surviving IPV. Such education can be provided to trainees at any stage and across multiple specialties (e.g., medical, nursing, public health, or social work). There is potential to replicate this mutual learning curriculum in a wide variety of other settings serving mothers and children.
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http://dx.doi.org/10.15766/mep_2374-8265.10492DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6440431PMC
November 2016