A New Health Care Paradigm: The Power of Digital Health and E-Patients

The integration of digital health into the field of medicine has seen a marked increase with the advancement of technology. Before the pandemic, a marked portion of the adult population, more than 66%, owned smartphones, and approximately 15% owned wearables. The widespread use of such devices, along with the effect of COVID-19 pandemic, has led to a transformation in health care culture that prioritizes cocreation, codesign, and collaboration. This shift promotes a model of health care centered on patient empowerment and self-management. In a recent interview with Dave deBronkart, known as e-Patient Dave, we revisited the possibilities of this new approach aimed at empowering, engaging, and equipping e-patients in the context of the pandemic. This interview with deBronkart was originally used for a graduate course on digital health. However, after noticing many reoccurring themes throughout the discussion, we decided to further explore this matter. It was discovered that participatory medicine is a new paradigm in health care, which challenges the conventional, paternalistic model and emphasizes the importance of a collaborative relationship between patients and providers. The realization of the full potential of health care can be achieved by promoting patient engagement and activation through the adoption of participatory medicine.

The Virtual Interview Experience for MATCH 2021: A Pilot Survey of General Surgery Residency Program Directors.

BACKGROUND: Virtual interviews (VIs) for the 2020 residency application season were mandated as a result of the COVID-19 pandemic. We aimed to determine the perspectives of general surgery (GS) program directors (PDs) on the benefits and drawbacks of VIs. METHODS: A 14-item survey was emailed to all GS PDs from programs identified on the American Council for Graduate Medical Education website. Program directors were asked about the cost-time benefit of VIs, its ability to assess candidates, and their thoughts on the future of VIs for evaluating residency applicants. RESULTS: 60 PDs responded corresponding to a response rate of 21%. While 93% agreed/strongly agreed that VIs were less expensive, only 35% found VIs to be less time-consuming. 75% and 67%, respectively, disagreed/strongly disagreed that VIs allowed for an easier assessment of an applicant's fit, and personality and communication skills. Almost one-half of our survey respondents suggested that VIs made the selection committee rely more heavily on objective applicant data. Almost two-thirds of GS PDs suggested that they would adopt both VI and in-person interview formats for future application cycles. The median [interquartile range] cost saved through the implementation of VIs was US$ 4500 [1625 - 10 000]. CONCLUSION: Remarkably, VIs have been swiftly imbibed by all residency programs and many aspects of the VI experience were positive. While MATCH 2021 has definitely proved to be one of its kind, the implementation of VIs has been met with overall broad success and a promising future awaits this novel modality of resident selection to GME programs in the United States.

Multi-System Inflammatory Syndrome Presenting as Non-Specific Colitis: A Medical Diagnosis with a Surgical Presentation.

A 20-year-old woman with previous COVID-19 diagnosis presented with abdominal pain and colitis on CT scan. She was admitted in septic shock, with etiology of colitis unclear. After resuscitation, antibiotics, and steroids, she clinically deteriorated. Worsening Clostridioides difficile infection was most likely and she was taken to the operating room. Intraoperatively, only a segment of transverse colon appeared abnormal on gross and endoscopic evaluation. Total colectomy was deferred in favor of segmental resection. Given her unusual disease pattern and recent COVID-19 infection, diagnosis of MIS-C was considered. Steroids were continued and treatment broadened to include heparin and IVIG. The patient returned to the operating room for planned reexploration, endoscopy, and end colostomy. On hospital day three, the patient had an acute mental status change. Computed tomography demonstrated acute cerebral edema with brainstem herniation. The family chose comfort-care measures. Final pathology from the transverse colon demonstrated COVID-19-associated vasculitis.

Home monitoring with connected mobile devices for asthma attack prediction with machine learning.

Monitoring asthma is essential for self-management. However, traditional monitoring methods require high levels of active engagement, and some patients may find this tedious. Passive monitoring with mobile-health devices, especially when combined with machine-learning, provides an avenue to reduce management burden. Data for developing machine-learning algorithms are scarce, and gathering new data is expensive. A few datasets, such as the Asthma Mobile Health Study, are publicly available, but they only consist of self-reported diaries and lack any objective and passively collected data. To fill this gap, we carried out a 2-phase, 7-month AAMOS-00 observational study to monitor asthma using three smart-monitoring devices (smart-peak-flow-meter/smart-inhaler/smartwatch), and daily symptom questionnaires. Combined with localised weather, pollen, and air-quality reports, we collected a rich longitudinal dataset to explore the feasibility of passive monitoring and asthma attack prediction. This valuable anonymised dataset for phase-2 of the study (device monitoring) has been made publicly available. Between June-2021 and June-2022, in the midst of UK's COVID-19 lockdowns, 22 participants across the UK provided 2,054 unique patient-days of data.

Plant-derived single domain COVID-19 antibodies.

Data show a decrease in the risk of hospitalization and death from COVID-19. To date, global vaccinations for SARS-CoV-2 protections are underway, but additional treatments are urgently needed to prevent and cure infection among naïve and even vaccinated people. Neutralizing monoclonal antibodies are very promising for prophylaxis and therapy of SARS-CoV-2 infections. However, traditional large-scale methods of producing such antibodies are slow, extremely expensive and possess a high risk of contamination with viruses, prions, oncogenic DNA and other pollutants. The present study is aimed at developing an approach of producing monoclonal antibodies (mAbs) against SARS-CoV-2 spike (S) protein in plant systems which offers unique advantages, such as the lack of human and animal pathogens or bacterial toxins, relatively low-cost manufacturing, and ease of production scale-up. We selected a single N-terminal domain functional camelid-derived heavy (H)-chain antibody fragments (VHH, AKA nanobodies) targeted to receptor binding domain of SARS-CoV-2 spike protein and developed methods of their rapid production using transgenic plants and plant cell suspensions. Isolated and purified plant-derived VHH antibodies were compared with mAbs produced in traditional mammalian and bacterial expression systems. It was found that plant generated VHH using the proposed methods of transformation and purification possess the ability to bind to SARS-CoV-2 spike protein comparable to that of monoclonal antibodies derived from bacterial and mammalian cell cultures. The results of the present studies confirm the visibility of producing monoclonal single-chain antibodies with a high ability to bind the targeted COVID-19 spike protein in plant systems within a relatively shorter time span and at a lower cost when compared with traditional methods. Moreover, similar plant biotechnology approaches can be used for producing monoclonal neutralizing antibodies against other types of viruses.

Preliminary Pilot-Testing of Social Determinants of Health Screener for Individuals With Intellectual and Developmental Disabilities in Med-Peds.

In the United States, one in six children has an intellectual and/or developmental disability (I/DD), including attention deficit hyperactivity disorder (ADHD), autism, cerebral palsy, learning disabilities, seizures, and developmental delays, with or without intellectual impairment. Individuals with I/DDs experience disproportionate rates of immune, metabolic, cardiovascular, and neurological disorders, as well as anxiety, depression, functional somatic symptoms, and other co-occurring physical and mental health conditions. During the coronavirus disease 2019 (COVID-19) pandemic, having an I/DD emerged as one of the strongest predictors of contracting and dying from COVID-19. These findings spurred increased attention toward the myriad health inequities affecting this population well before the pandemic. While inequities for individuals with I/DD can be traced to many factors, social determinants of health (SDOH) - the underlying social, economic, and environmental conditions that lead to poor health outcomes and high healthcare costs - are key contributors. Our interdisciplinary combined internal medicine and pediatrics (Med-Peds) team of physicians, psychologists, and researchers within a large, diverse, academic health system aimed to pilot-test the implementation of a five-item SDOH screener within a Med-Peds specialty clinic focused on the developmental needs of individuals with I/DD and their families (Leadership Education in Neurodevelopmental Disabilities {LEND}) and a general primary care practice (PCP). The SDOH screener tested in this initiative includes five items from the Accountable Health Communities (AHC) Health-Related Social Needs Screening Tool (HRSN) assessing social isolation, food insecurity, transportation, and paying for basic needs, such as housing and medical care. In this study, we describe the process of implementing this screener and collecting initial pilot data from 747 patients between October 2022 and April 2023 across the LEND and the primary care practice. We also highlight the challenges and opportunities identified during the mid-way point of implementation and pilot testing. The results of this pilot study revealed low response rates among SDOH screeners, spurring several measures to increase uptake, including increasing the accessibility of the screener and ensuring the screener results in effective referrals. We call on additional Med-Peds healthcare teams without universal SDOH screening protocols in place - particularly those serving the I/DD population - to consider adopting these practices.

A Cryptic Case of an Anaerobic Hepatic Abscess Following a Cesarean Section.

Postpartum infectious complications can present with a wide range of nonspecific symptoms. Herein, we describe a complicated late postpartum presentation of recurrent fever following a cesarean delivery complicated by chorioamnionitis. Following discharge, the patient experienced cyclical fever and was treated with antipyretics as an outpatient. The patient continued to experience symptoms and reported to the hospital for further evaluation. Initially thought to be septic pelvic thrombophlebitis, the patient was trialed on clindamycin and gentamycin without resolution of symptoms. After extensive evaluation, the fevers were found to be the result of an infected periuterine hematoma and a concomitant subcapsular inferior hepatic abscess. Bacterial cultures isolated two rare anaerobic organisms: Peptoniphilus ssp. and Finegoldia magna. Source control was achieved by drainage of the two abscesses followed by antibiotic treatment with ertapenem and metronidazole, and the patient recovered successfully. This is the first reported case, to the authors' knowledge, of this complicated postpartum picture due to these anaerobic organisms.

Rehabilitation Characteristics and Outcomes for Lung Transplantation for COVID-19: A Case Series.

OBJECTIVE: Severe coronavirus disease 2019 (COVID-19) can result in irreversible lung damage, with some individuals requiring lung transplantation. The purpose of this case series is to describe the initial experience with the rehabilitation and functional outcomes of 9 patients receiving a lung transplant for COVID-19. METHODS: Nine individuals, ranging in age from 37 to 68 years, received bilateral orthotopic lung transplantation (BOLT) for COVID-19 between December 2020 and July 2021. Rehabilitation was provided before and after the transplant, including in-hospital rehabilitation, postacute care inpatient rehabilitation, and outpatient rehabilitation. RESULTS: Progress with mobility was limited in the pretransplant phase despite rehabilitation efforts. Following transplantation, 2 individuals expired before resuming rehabilitation, and 2 others had complications that delayed their progress. The remaining 5 experienced clinically important improvements in mobility and walking capacities. CONCLUSION: Considerable rehabilitation resources are required to care for individuals both before and after BOLT for COVID-19. Rehabilitation can have a profound impact on both functional and clinical outcomes for this unique patient population. IMPACT: There is limited literature on the rehabilitation efforts and outcomes for patients who received BOLT for COVID-19. Occupational therapists and physical therapists play an important role during the pretransplant and posttransplant recovery process for this novel patient population. LAY SUMMARY: Patients with a bilateral orthotopic lung transplant due to COVID-19 require a unique rehabilitation process. They have significant difficulties with activities of daily living and functional mobility across the pretransplant and posttransplant continuum of care, but progressive gains in functional performance may be possible with a comprehensive multidisciplinary rehabilitation program.

Effect of the COVID-19 Pandemic on Rates and Epidemiology of Clostridioides difficile Infection in One VA Hospital (preprint)

The COVID-19 pandemic was associated with increases in some healthcare-associated infections. We investigated the impact of the pandemic on rates and molecular epidemiology of Clostridioides difficile infection (CDI) within one VA Hospital. We anticipated that the potential widespread use of antibiotics for pneumonia during the pandemic might increase CDI rates given that antibiotics are a major risk for CDI. Hospital data on patients with CDI and recurrent CDI (rCDI) were reviewed pre-COVID-19 pandemic (2015 to 2019) and during the pandemic (2020 - 2021). Restriction endonuclease analysis (REA) strain typing was performed on CD isolates recovered from stool samples collected from 10/2019 – 3/2022. CDI case numbers declined 43.2% in 2020 – 2021 compared to the annual mean over the previous 5 years. Stool test positivity rate was also lower during the COVID-19 pandemic (14.3% vs. 17.2%; P = 0.013). Although inpatient volume declined, rates of CDI among inpatients were reduced by 34.2% in 2020 – 2021. Mean monthly cases of rCDI also declined significantly after 2020 [3.38 (95% CI: 2.89 – 3.87) vs. 1.92 (95% CI: 1.27 – 2.56); P = <0.01]. Prior to the pandemic, REA group Y was the most prevalent CD strain among the major REA groups (27.3%). During the first wave of the pandemic from March 8, 2020, through June 30, 2020, there was an increase in the relative incidence of REA group BI (26.7% vs. 9.1%. After adjusting for CDI risk factors, a multivariable logistic regression model revealed that odds of developing an REA group BI CDI increased during the first pandemic wave (OR 6.41, 95% CI: 1.03 – 39.91) compared to the pre-pandemic period. In conclusion, the incidence of CDI and rCDI decreased significantly during the initial waves of the COVID-19 pandemic. In contrast, REA BI (Ribotype 027), a virulent, previously epidemic CD strain and frequently associated with hospital transmission and outbreaks, reappeared as a prevalent strain during the first wave of the pandemic.

COVID-19 Vaccination is Associated with Reduced Outpatient Antibiotic Prescribing In Older Adults with Confirmed SARS-CoV-2: A Population Wide Cohort Study.

BACKGROUND: Antibiotics are frequently prescribed unnecessarily in outpatients with COVID-19. We sought to evaluate factors associated with antibiotic prescribing in those with SARS-CoV-2 infection. METHODS: We performed a population-wide cohort study of outpatients 66 years or older with PCR-confirmed SARS-CoV-2 from January 1st 2020 to December 31st 2021 in Ontario, Canada. We determined rates of antibiotic prescribing within 1-week before (pre-diagnosis) and 1-week after (post-diagnosis) reporting of the positive SARS-CoV-2 result, compared to a self-controlled period (baseline). We evaluated predictors of prescribing, including a primary series COVID-19 vaccination, in univariate and multivariable analyses. RESULTS: We identified 13,529 eligible nursing home residents and 50,885 eligible community dwelling adults with SARS-CoV-2 infection. Of the nursing home and community residents, 3,020 (22%) and 6,372 (13%) received at least one antibiotic prescription within 1 week of a SARS-CoV-2 positive result, respectively. Antibiotic prescribing in nursing home and community residents occurred at 15.0 and 10.5 prescriptions per 1000 person-days pre-diagnosis and 20.9 and 9.8 per 1000 person-days post-diagnosis, higher than the baseline rates of 4.3 and 2.5 prescriptions per 1000 person-days. COVID-19 vaccination was associated with reduced prescribing in nursing home and community residents, with adjusted post-diagnosis IRRs of 0.7 (95%CI 0.4-1) and 0.3 (95%CI 0.3-0.4) respectively. CONCLUSIONS: Antibiotic prescribing was high and with little or no decline following SARS-CoV-2 diagnosis, though was reduced in COVID-19 vaccinated individuals, highlighting the importance of vaccination and antibiotic stewardship in older adults with COVID-19.

Single Ventricle Reconstruction III: Brain Connectome and Neurodevelopmental Outcomes: Design, Recruitment, and Technical Challenges of a Multicenter, Observational Neuroimaging Study.

Patients with hypoplastic left heart syndrome who have been palliated with the Fontan procedure are at risk for adverse neurodevelopmental outcomes, lower quality of life, and reduced employability. We describe the methods (including quality assurance and quality control protocols) and challenges of a multi-center observational ancillary study, SVRIII (Single Ventricle Reconstruction Trial) Brain Connectome. Our original goal was to obtain advanced neuroimaging (Diffusion Tensor Imaging and Resting-BOLD) in 140 SVR III participants and 100 healthy controls for brain connectome analyses. Linear regression and mediation statistical methods will be used to analyze associations of brain connectome measures with neurocognitive measures and clinical risk factors. Initial recruitment challenges occurred that were related to difficulties with: (1) coordinating brain MRI for participants already undergoing extensive testing in the parent study, and (2) recruiting healthy control subjects. The COVID-19 pandemic negatively affected enrollment late in the study. Enrollment challenges were addressed by: (1) adding additional study sites, (2) increasing the frequency of meetings with site coordinators, and (3) developing additional healthy control recruitment strategies, including using research registries and advertising the study to community-based groups. Technical challenges that emerged early in the study were related to the acquisition, harmonization, and transfer of neuroimages. These hurdles were successfully overcome with protocol modifications and frequent site visits that involved human and synthetic phantoms.

Repair of Acute Respiratory Distress Syndrome in COVID-19 by Stromal Cells (REALIST-COVID Trial): A Multicentre, Randomised, Controlled Trial.

RATIONALE: Mesenchymal stromal cells (MSCs) may modulate inflammation, promoting repair in COVID-19-related Acute Respiratory Distress Syndrome (ARDS). OBJECTIVES: We investigated safety and efficacy of ORBCEL-C (CD362-enriched, umbilical cord-derived MSCs) in COVID-related ARDS. METHODS: This multicentre, randomised, double-blind, allocation concealed, placebo-controlled trial (NCT03042143) randomised patients with moderate-to-severe COVID-related ARDS to receive ORBCEL-C (400million cells) or placebo (Plasma-Lyte148). MEASUREMENTS: The primary safety and efficacy outcomes were incidence of serious adverse events and oxygenation index at day 7 respectively. Secondary outcomes included respiratory compliance, driving pressure, PaO2/FiO2 ratio and SOFA score. Clinical outcomes relating to duration of ventilation, length of intensive care unit and hospital stays, and mortality were collected. Long-term follow up included diagnosis of interstitial lung disease at 1 year, and significant medical events and mortality at 2 years. Transcriptomic analysis was performed on whole blood at day 0, 4 and 7. MAIN RESULTS: 60 participants were recruited (final analysis n=30 ORBCEL-C, n=29 placebo: 1 in placebo group withdrew consent). 6 serious adverse events occurred in the ORBCEL-C and 3 in the placebo group, RR 2.9(0.6-13.2)p=0.25. Day 7 mean[SD] oxygenation index did not differ (ORBCEL-C 98.357.2], placebo 96.667.3). There were no differences in secondary surrogate outcomes, nor mortality at day 28, day 90, 1 or 2 years. There was no difference in prevalence of interstitial lung disease at 1year nor significant medical events up to 2 years. ORBCEL-C modulated the peripheral blood transcriptome. CONCLUSION: ORBCEL-C MSCs were safe in moderate-to-severe COVID-related ARDS, but did not improve surrogates of pulmonary organ dysfunction. Clinical trial registration available at www. CLINICALTRIALS: gov, ID: NCT03042143. This article is open access and distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/).

Financing sport post-COVID-19: using Modern Monetary Theory (MMT) to help make a case for economic recovery through spending on sport and recreation

This commentary aims to explore the challenges of financing sport in light of the economic and health questions posed by the COVID-19 outbreak. Governments will have to spend large sums of public money to stimulate recovery;therefore, it is asked: how should sport and recreation spending be part of recovery plans? The case of the Montreal Olympics debt and deficit disaster is re-examined. It is argued that if the federal government (a currency issuer) underwrote the games many of the issues that followed may have been avoided. Therefore, this commentary challenges sport and leisure scholars to think about how sport and recreation could be part of the solution when fiscal policy is becoming the preferred antidote to the social and economic consequences of the Coronavirus pandemic.

A Scoping Review of the Impact of COVID-19 on Kidney Transplant Patients in the United States.

SARS-CoV-2, responsible for the COVID-19 pandemic, is a highly infectious virus that quickly became and continues to be a public health emergency, given the severe international implications. Immunocompromised patients, such as those undergoing kidney transplantation, are at an increased risk for severe illness from COVID-19 and require hospitalization for more aggressive treatment to ensure survival. COVID-19 has been infecting kidney transplant recipients (KTRs), affecting their treatment protocols, and threatening their survival. The objective of this scoping review was to summarize the published literature regarding the impact of COVID-19 on KTRs in the United States in terms of prevention, various treatment protocols, COVID-19 vaccination, and risk factors. The databases such as PubMed, MEDLINE/Ebsco, and Embase were used to search for peer-reviewed literature. The search was restricted to articles that were published on KTRs in the United States from January 1, 2019, to March 2022. The initial search yielded 1,023 articles after removing duplicates, leading to a final selection of 16 articles after screening with inclusion and exclusion criteria. Four domains emerged from the review: (1) impacts of COVID-19 on performing kidney transplants, (2) impacts of COVID-19 vaccinations on KTRs, (3) outcomes of treatment regiments for KTRs with COVID-19, and (4) risk factors associated with an increased mortality rate of COVID-19 in KTRs. Waitlisted patients for kidney transplants had a higher risk of mortality compared to nontransplant patients. COVID-19 vaccinations in KTRs are found to be safe, and the immune response can be improved by placing patients on a low dose of mycophenolate before vaccination. Withdrawal of immunosuppressants showed a mortality rate of 20% without increasing the rate of acute kidney injury (AKI). There is evidence to support that kidney transplantation with the accompanying immunosuppressant regimen can provide KTRs with better COVID-19 infection outcomes compared to waitlisted patients. Hospitalization, graft dysfunction, AKI, and respiratory failure were the most common risk factors that increased the risk of mortality in COVID-19-positive KTRs. Withdrawing KTRs from immunosuppressive drugs increased the mortality rate. Further studies are needed to investigate the effects of specific drugs and dosages on the severity and mortality rate of COVID-19 in KTRs.

Best Practice Recommendations for Stroke Vascular Imaging During Iodinated Contrast Shortage.

GE Healthcare© announced on April 19, 2022, that their main factory and distributor of iodinated contrast had experienced a temporary shutdown because of COVID-19 outbreak in Shanghai, China. This, along with other supply chain issues, led to a worldwide shortage of iodinated contrast agents, Omnipaque and Visipaque. Our Comprehensive Stroke Center was confronted with the cascading effect of this iodinated contrast material shortage. We took immediate steps to revise our protocols and processes to continue to provide high-quality care to our stroke patients. A multidisciplinary working group comprised of representatives of our stroke center, including vascular neurology, diagnostic neuroradiology, and neurovascular surgery, urgently met to brainstorm how to mitigate the shortage. We established parameters and local guidelines for the use of CT angiography, CT perfusion, and digital subtraction angiography for stroke patients. In this article, we propose "best practice" recommendations from a single Joint Commission approved Comprehensive Stroke Center that can be used as blueprint by other hospital systems when navigating potential future supply chain issues, to provide consistent high-quality stroke care.

Doubling down on best practices: reflecting on teaching physiology during the COVID-19 pandemic.

As we pass the third anniversary of the World Health Organization's declaration of the SARS-CoV-2 global pandemic, it is beneficial to reflect upon how physiology education adapted to the challenges of the pandemic. At the initial stages of the pandemic, many educators were faced with the challenge of quickly transitioning to emergency remote teaching (ERT), requiring shifts in teaching methodology and laboratory structure to adapt to the pandemic normal. In this review, we provide a broad overview of the efforts made by the community of educators associated with the American Physiological Society during the pandemic to encourage best practices in teaching, maintain course and program goals during ERT, and innovate in physiology education. We also highlight diversity, equality, and inclusion work that was produced as the scientific community recommitted to tackling systemic and structural inequalities exacerbated by the pandemic and brought to the forefront by the Black Lives Matter movement. Finally, we examine the potentially long-lasting effects of the pandemic on education from both the student and faculty standpoints and how doubling down on what we learned can be beneficial to the future of physiology education.NEW & NOTEWORTHY This literature review examines and categorizes the repository of publications in physiology education that occurred during and related to the COVID-19 pandemic.

VIRTUAL REALITY SIMULATION SHOWS GREAT PROMISE

Virtual reality (VR) simulation pairs best practices for simulation training with gaming. This education modality has been used primarily in student nurse education but is emerging as a valuable tool in competency training of new and experienced nurses. The COVID-19 pandemic brought challenges of providing a safe environment to teach and practice skills. VR simulation provides a realistic scenario without the risk of harm to the learner or patient. Benefits of this education modality include reduced supply usage and cost;it is, low risk and low anxiety;it is not location or time bound, it can be customized, and The ability to create a consistent simulation experience with low variation in a safe learning environment leads to highly reliable education. The purpose of the VR simulation pilot was to measure knowledge, skill, and self-efficacy of cleaning a small hazardous drug spill before and after completing a virtual reality simulation. The pilot was conducted at Northwestern Memorial Hospital, a Magnet designated, academic medical center with greater than 900 beds in Chicago. After completion of the Cleaning a Hazardous Drug Spill Virtual Reality Simulation, learners will be able to choose the PPE and supplies needed to safely clean a hazardous drug spill, determine the correct order of donning and doffing PPE, and perform the steps to clean a hazardous drug spill. The learning outcomes included demonstrating how to respond and clean a small hazardous drug spill along with feeling prepared to clean a hazardous drug spill in their work environment. Pre- and post- evaluations were collected to measure knowledge, skill, self-efficacy, and satisfaction. An increase in knowledge and skills were found. learners were satisfied with their experience and interested in using VR simulation to learn new skills. According to the data, 100% of learners agreed or strongly agreed that after completing the VR simulation that they felt prepared to clean a hazardous drug spill in their setting. VR simulation is a fun and effective tool to teach novice and experienced nurses. Our pilot and recent studies show that VR simulation has comparable learning outcomes to traditional training simulation. Simulation with VR is an emerging supplement to didactic education, supplying the hands-on training nurses need, and shows great promise for the modern healthcare setting.