The challenges of embedding advanced care planning into a Haematology service

Following an increased need for individual patient escalation plans during the COVID-19 pandemic we recently created a working group to embed Advance Care Planning (ACP) into our service. Modern ACP is not only about end-of- life planning, it involves meaningful conversations and supporting patients to make decisions throughout all stages of their disease and treatment. With early conversations and the opportunity to pre plan, the stress and anxiety attached to the difficult decisions at a time when someone may be acutely unwell should become easier (from the perspective of both staff and patients). We carried out a preproject audit to ascertain patient opinions on how we could embed ACP into our service. 50 patients were offered a questionnaire, 38 chose to partake. Result(s): 100% (38) of patients had never been approached by a nurse to discuss ACP. 82% (31 out of 38) said they would not want to be approached about ACP. 18% (7 pts) would like to be approached but 13% (5pts) noted only if end of life. On asking when the best time to be approached: three patients said 'at diagnosis', two said 'anytime', one said 'never', five said 'when ready' and seven said 'end of life only'. Suggestions on the best way to raise ACP issues, five said poster displays (one noting the need for this poster to be positive and also available in Welsh), four suggested routine discussions in the current appointment and five people suggested a separate appointment. Other comments included, I only want to discuss these issues with my solicitor, I would like my family to be involved, make sure the nurses can answer questions. Average age was 68.5 years (range 49-85). Discussion(s): This was a limited audit on an outpatient population, but it raised a number of important issues. The actual carrying out of an audit on an emotive subject highlighted one the difficulties of embedding ACP initiatives into a service with a quarter of patients choosing not to answer the questionnaire, and of those who chose to answer 83% said they did not necessarily want to be approached to discuss ACP. In addition, the terminology 'ACP' appeared confusing, many people linking it to end-of- life discussions or to legal aspects such as writing of Wills. The barriers this audit has highlighted, has helped to shape the future direction of our working group and highlighted the need for increased training.

Assessing the impact of COVID-19 and related interventions on poverty and economic growth in Pakistan: A structural path analysis

This study uses social accounting matrix multipliers and structural path analyses to estimate effects of COVID-19 and related fiscal stimuli on five household groups. The COVID-19 lockdown increased poverty in Pakistan by 15%, which was addressed using a $1.5 billion, digitally implemented Ehsaas Emergency Cash (EEC) program that reached 14.8 million poor households. The study's models show that the largest multipliers from Ehsaas program finance were in agriculture, as a 1 Rupee shock adds 0.225 Rupee income to households. About 30% of that gain was estimated to go to poor farm families. In contrast, our models find that construction and trade growth added three times as much income to poor nonfarm and urban households as to farm households. However, those sectors added only one third as much total income as agriculture. From the structural path analysis, the importance of capital assets in generating income was seen, as was the possibility of greater poverty reduction from sectors with proportionally fewer intermediate inputs and more value added. © 2023 The Authors. Applied Economic Perspectives and Policy published by Wiley Periodicals LLC on behalf of Agricultural & Applied Economics Association.

The Research Imagination During COVID-19: Rethinking Norms of Group Size and Authorship in Anthropological and Anthropology-Adjacent Collaborations

This article explores some of the ways in which the COVID-19 pandemic has served as a collective critical event for anthropologists and other social scientists, examining how it has promoted new configurations of the research imagination. We draw on our own experiences of participating in a team of 17 researchers, hailing from anthropology and anthropology-adjacent disciplines, to research social life in Aotearoa/New Zealand during the pandemic, examining how our own research imaginations were transformed during, and via, the process of our collaboration. When our project first began, many of us had doubts reflective of norms, prejudices and anxieties that are common in our disciplines: that the group would be too large to function effectively, or that it would be impossible to develop an approach to authorship that would allow everyone to feel their contributions had been adequately recognised. In practice, the large group size was a key strength in allowing our group to work effectively. Difficulties with authorship did not arise from within the group but from disconnects between our preferred ways of working and the ways authorship was imagined within various professional and publishing bodies. We conclude that large-scale collaborations have many points in their favour, and that the research imaginations of funders, journals, universities and professional associations should be broadened to ensure that they are encouraged, supported and adequately rewarded. © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

Pharm Aco Kin Etics of Remdesivir and Its Metabolites in Participants with Moderate and Severe Hepatic Impairment

BACKGROUND: Remdesivir (RDV) is an RNA polymerase inhibitor approved for treatment of COVID-19 (200 mg loading dose, 100 mg qd thereafter) in adult and pediatric patients, primarily metabolized by the high-capacity carboxylesterase 1 pathway (80% of metabolism), and by cathepsin A and CYP3A (10% each). The extensive hepatic contribution to RDV elimination and the prevalence of liver comorbidities in COVID-19 patients warranted a study in participants with hepatic impairment (HI). METHOD(S): This is a phase 1, open-label study of RDV consisting of moderate and severe HI participants and healthy matched controls (HMC) based on age (+/- 10 years), sex, and BMI (+/- 20%). Participants received a single 100 mg IV dose of RDV and remained in the clinic for 8 days. The primary endpoint was pharmacokinetic (PK) parameters of RDV and metabolites. RESULT(S): Preliminary PK and safety data from 10 moderate and 6 severe HI participants and their HMC are available. The average PK fold-change for all analytes and matrices assessed in the study are presented (Table). No serious treatment-related adverse events and no clinically significant changes in participant lab values were reported. CONCLUSION(S): The 1.52 RDV AUCinf fold increase is within expected ranges and justifies no dose adjustment in COVID-19 patients with impaired hepatic function. (Table Presented).

Reproducing or Reducing Inequality? The Case of Summer Learning Programs

Can summer programs, as remedial supplements to regular schooling, extend learning opportunities and other benefits to disadvantaged students? To frame this question, we compare logics from "social reproduction” and "partial compensation” perspectives, and then apply them to a large mixed method study of four kinds of summer programs in Ontario. Drawing on quantitative data on over 10,000 students and qualitative data from interviews with over 200 teachers and parents, we examined patterns of student recruitment and participation, social valuations, and academic outcomes. We found that all summer programs successfully recruited disadvantaged students without stigmatizing them, and raised their average achievement without widening pre-existing gaps. We interpret these findings as being consistent with the "partial compensation” perspective, and discuss related policy implications that include COVID-19 learning recovery strategies © 2023 Canadian Society for the Study of Education/Société canadienne pour l'étude de l'éducation

Is there still a role for routine histology in cholecystectomies for benign disease?

Background: A movement towards selective histology for benign gallbladder disease is evolving in the United Kingdom (UK). Studies propose the reliance on macroscopic features to identify incidental gallbladder cancer (IGBC). We aimed to investigate the rate of dysplastic gallbladder histology, the rate of subtotal cholecystectomy and identify any selection criteria for selective histology. Method(s): A retrospective observational study examining patients who underwent a cholecystectomy, amid the COVID-19 pandemic, between January 2020 and June 2021. This study was carried out in a large Trust in the West Midlands, UK. Multivariate logistical regression models were used to identify patient factors associated with IGBC and compare outcomes between total and subtotal cholecystectomy. Result(s): There were 959 patients;631 (65.8%) elective and 328 (34.2%) emergency cholecystectomies. Median age was 48 (35-59) years, and 724 (75.5%) patients were female. 27 (2.8%) patients had a subtotal cholecystectomy with worse post-operative complications (Clavien-Dindo grade 3+, OR 4.69, p=0.026), however no patient suffered a common bile duct injury. Eight (0.8%) patients had IGBC of which 6/8 were diagnosed as cholelithiasis on ultrasound. Five IGBCs had no macroscopic features. One patient needed further surgery and chemotherapy. Gallbladder polyps on ultrasound was the only patient factor associated with increased likelihood of IGBC (OR 14.49, p=0.014). Conclusion(s): We support the current recommendation of the UK Royal College of Pathologists to routinely examine all cholecystectomies removed for benign disease, given that macroscopic features may be absent in IGBC and no clear patient factors to support a selective approach.

Swallowing and communication assessment in tracheostomy patients: Multi-disciplinary-led quality improvement in a busy tertiary teaching hospital

Introduction: Intensive care patients often have complex swallowing and communication needs. These require coordinated input from the multi-disciplinary team. Increasing evidence highlights the role of speech and language therapy (SLT) within the critical care environment1 and this is represented well in national recommendations specific to patients with tracheostomies. Approximately 10-15% of ICU patients will have a tracheostomy nationally.2 SLT provide expertise in assessment and management of communication and swallowing difficulties, which can vastly improve psychosocial well-being and promote early safe enteral feeding for our patients.3 In 2014 On the right trache?4 found that 52% of patients with a tracheostomy suffered with dysphagia, however only 27% critical care patients had input from SLT. Objectives: To improve the assessment of swallowing and communication in patients undergoing tracheostomy ventilation at the Royal Infirmary of Edinburgh, to comply with Scottish Intensive Care Society Audit Group (SICSAG) quality indicator 2.3. This guidance stipulates all tracheostomy patients should have communication and swallowing needs assessed during ventilator wean.5 Methods: Four distinct areas of intervention were implemented. Pre-populated review text was added to NHS Lothian's clinical notation system (InterSystems TrakCare®), prompting nursing staff to consider swallowing, tracheostomy issues and SLT referral. These were refined between audit cycles. SLT were invited to join safety briefs to identify tracheostomy patients, as well as other patients with complex swallowing needs. This was an opportunity to raise awareness, educate, and prioritise workload. New guidelines for nurse-led swallowing observations were developed and disseminated amongst teams. Finally, staff were offered relevant educational sessions. Baseline data was collected in 2019;serial data collection was then during October - November 2020 and in June - July 2021 following the interventions. Results: All patients who received tracheostomy ventilation were audited (n=31). This showed that very few patients had swallowing and communication assessed adequately. Only 16.1% (n=5) patients had a regular nursing swallowing assessment on the majority of critical care days (>50%). Referral to SLT was often very late when patients were approaching de-cannulation and on many occasions by the time the SLT team were involved patients had already been de-cannulated. Following the intervention period, it became apparent that awareness of swallowing requirements had improved. By mid 2021, 58.9% more patients had swallowing assessed as part of daily care. Additionally, 81.2% of patients had SLT reviews on the unit demonstrating a sustained increase from late 2020. There was a notable increase in the quality of assessments after initial SLT review. Conclusion: Using quality improvement methodology our multidisciplinary team was able to substantially increase the quality of swallowing assessment within our ICU, despite the challenges of the COVID-19 pandemic. Our unit now complies with SICSAG quality indicator 2.3. This is in keeping with national recommendations for a multidisciplinary approach to care of tracheostomy patients. Patients with increased risk of dysphagia are being identified earlier and are more likely to progress and be established on enteral feeding early, which may subsequently reduce the burden of nasogastric feeding, total parenteral nutrition and even related invasive IV access.

Vital best practices for antiracist patient engagement in AYA oncology research and advocacy: A Delphi study of BIPOC AYA experts

Background: In the thick of the ongoing global crises of the COVID-19 pandemic, uprisings against anti-Black racism and police brutality, and anti-Asian racism and violence, Black, indigenous, and people of color (BIPOC) adolescent and young adult (AYA) cancer patients may be particularly vulnerable and exploited. Whilst embroiled in sociopolitical complexity, BIPOC AYAs are increasingly called upon to contribute as patient advocates in AYA oncology research and advocacy. Researchers, clinicians, and advocates in AYA oncology must dismantle long-standing racism and create meaningful structural change. The purpose of this study is to derive vital best practices for implementing antiracist patient engagement in AYA oncology research and advocacy that are co-developed by BIPOC AYA cancer patients and oncology professionals. Methods: We utilized a modified Delphi technique with a panel of BIPOC AYA cancer patients (n = 32) to build consensus opinions on professional recommendations from a prior study (Cheung et al., 2021), and to generate antiracist best practices in patient engagement. The Delphi study was comprised of three consecutive and iterative survey rounds over the course of 8 months in 2021;participants were BIPOC AYAs diagnosed with cancer between ages 15-36 years. Results: Results detail best practices for the implementation of antiracist patient engagement across all research activities within the Patient-Centered Outcomes Research Institute's (PCORI) Framework for Patient Engagement. For example, BIPOC AYAs agreed with oncology professionals' high priority recommendation for including BIPOC AYAs at the highest levels of decision making in research topic selection. As such, a best practice is for researchers to ensure that such representatives not only hold BIPOC AYA identity, but also hold direct experience with the particular oncology diagnosis, issue, or other outcome of interest. Additionally, BIPOC AYAs concurred with oncology professionals' high priority for “transparency, honesty, and trust” as a core principle for best practices in patient engagement. They further explained that trustworthy relationships are especially important when collaborating with teens and young adults, who are developmentally just coming into their own. When describing successful experiences of inclusion, participants ranked “build collaborative relationships with BIPOC AYA communities and listen to patients not usually heard” and “recruit a diverse range of BIPOC patients and let them give actual input into the study” as the highest priority best practices. Conclusions: Findings from this study are instructional for AYA oncology researchers, clinicians, and advocates to prevent harmful tokenism and implement genuine antiracist inclusion to advance health equity. Future research should investigate best practices within unique clinical settings.

PREP DURING THE PANDEMIC;AN AUDIT OF HIV AND RENAL FUNCTION TESTING

Introduction BHIVA guidelines recommend that those prescribed pre-exposure prophylaxis (PrEP) have 3-monthly HIV testing and appropriate monitoring of renal function. The aim of this audit was to assess if these tests were being reliably completed, despite restricted access to Sexual Health Services during COVID restrictions. Methods Service-users prescribed ongoing PrEP June-August 2021 were identified via the electronic patient record (EPR). Those initiating PrEP were excluded. It was noted whether an HIV test result was recorded at time of prescription (or within 4 weeks), and if renal function was performed as per recommendations. STI diagnoses were noted. Results 82 PrEP-users were included. 31% used postal testing and 69% had tests in clinic. 95% had an HIV test within 4 weeks of PrEP prescription (87% of those using postal kits and 94% of those performing tests in clinic). No one missed renal function testing when required. STI rates were low. Discussion Whilst remote delivery of many services, including PrEP, will be retained beyond COVID restrictions, it is vital that those accessing PrEP also engage with testing and other health promotion activities. This audit has reassuringly demonstrated that those prescribed PrEP during this period had appropriate HIV and renal function follow-up (whether in-person or by post). Most not testing were low-risk due to behaviour change during COVID restrictions. When designing future PrEP delivery, we plan to perform a re-audit (during a period of no restrictions), and learn from the literature and other services how to ensure PrEP-users engage with testing despite a reduction in face-to-face services.

Clinical audit of POM-V/POM prescriptions by remote consultation via a veterinary video telemedicine smartphone application

Objective: To assess outcomes of a limited period (7 months) of remote video consultation with prescribing of prescription-only (POM) or prescription-only-veterinary (POM-V) medications by Royal College of Veterinary Surgeons (RCVS) registered veterinary surgeons to UK clients via a veterinary telemedicine smartphone application. Background: Objective evidence is needed to inform the veterinary profession on the impact that remote prescribing, without physical examination in person, has on animal health and welfare. During the COVID-19 pandemic, the RCVS allowed remote prescribing temporarily. Methods: Clinical records from all veterinary video consultations from 1 April-31 October 2020 were reviewed. Details were assessed pertaining to: signalment, body system/disease categories managed, referrals into practice, medication classes prescribed and outcomes following POM-V/POM medications. Records of adverse events and antimicrobial prescribing were reviewed. Results: 16.6% (3,541/21,383) of video consults had a POM-V/POM prescribed;with a (mild) adverse event rate of 0.8% (30/3541). Antibacterials were prescribed in 5.88% of all consultations (1,258/21,383), 99.3% (1249/1258) being first line. Follow-up on prescribing was available in 67.7% (2,399/3541) of cases. 89% (2135/2399) of all known treatment outcomes were complete or had an expected response to treatment. Dermatological disease was the most common body system/disease category seen and prescribed for. Conclusion: Low prescribing rates (including antibacterials) were recorded, treatments were efficacious and no harm was done by prescribing remotely via a veterinary video consult app. Application: Veterinary surgeons and governing bodies are invited to use the information provided in this clinical audit to inform decisions on the suitability of remote consultations and prescribing in veterinary medicine.

SAFETY of REMDESIVIR VS PLACEBO in NONHOSPITALIZED PATIENTS with COVID-19

Background: Remdesivir (RDV), a potent nucleotide inhibitor of the SARS-CoV-2 RNA-dependent RNA polymerase, effectively reduces COVID-19 related hospitalization in outpatients at high risk for progression to severe disease. However, limited data exist on the safety profile of RDV in this population. Methods: We conducted a Phase III placebo-controlled study evaluating a 3-day regimen of RDV in non-hospitalized patients who are at risk for disease progression (age>60 years or underlying comorbid condition). Patients were randomly assigned 1:1 to receive intravenous RDV (200 mg on day 1, 100 mg on days 2 to 3) or placebo (PBO). The primary safety endpoint was the proportion of patients with treatment-emergent adverse events (AEs). AEs were evaluated through day 28 and lab abnormalities were evaluated through day 14. Results: 562 patients were randomized and initiated treatment (279, RDV;283, placebo). Baseline characteristics were balanced between groups. Thirty percent were ≥60 years old and most common comorbidities were diabetes mellitus (62%), obesity (56%;median BMI, 30.7 kg/m2), and hypertension (48%). RDV was well tolerated with a similar rate of any AEs between groups (Table). Patients treated with RDV had fewer Grade ≥3 and serious AEs (SAEs) compared to PBO, but had more study-drug related AEs, with the most common one being nausea (18 [6.5%] in RDV vs. 10 [3.5%] in PBO). Grade 3 or higher ALT elevation was reported in 1 (0.4%) RDV vs. 2 (0.7%) PBO treated patients. Median change from baseline in AST, ALT, and bilirubin was similar between groups (Table). Grade 3 or higher decrease in creatinine clearance (CrCl) occurred more often in RDV vs. to PBO treated patients (5.6% vs 1.9% respectively). Most decreases in creatinine clearance occurred within the normal serum creatinine range, occurred after completion of RDV therapy, and resolved on follow-up. Median changes in CrCl from baseline were similar between groups and no renal AEs were reported (Table). Incidence of cardiac-related AEs was similar between RDV and PBO groups. All bradycardia events occurred in the PBO group. No patient experienced a serious AE or drug discontinuation due to hypersensitivity. Conclusion: Treatment with RDV was safe and well tolerated in non-hospitalized patients with risk factors for COVID-19 disease progression. Patients in the RDV group had similar type, incidence, and severity of AEs and lab abnormalities as those receiving PBO.

Fxr as a new therapeutic target for COVID-19

Background: Despite recent advances, the management of COVID19 is complicated by vaccine availability, the modest efficacy of existing treatments, and the potential for viral resistance. Therefore, there is a pressing need for new prophylactic and therapeutic agents. Modifying the expression of the SARS-CoV-2 entry receptor ACE2 could prevent viral infection and limit disease progression. Here, we identify that ACE2 expression is controlled by the transcription factor farnesoid X receptor (FXR) and demonstrate that ACE2 downregulation through FXR antagonism, using approved drugs, such as ursodeoxycholic acid (UDCA), could represent a novel therapeutic strategy to complement current approaches. Methods: Primary cholangiocyte, pulmonary and intestinal organoids were propagated using established protocols. Marker expression was assessed using singlecell RNA sequencing, QPCR, immunofluorescence and flow cytometry. FXR binding on DNA was assessed with chromatin immunoprecipitation. SARS-CoV-2 was isolated from bronchoalveolar lavage of a COVID19 patient. Viral load was measured via QPCR. Human livers not used for transplantation were perfused ex-situ using the metra (OrganOx) normothermic perfusion device. Serum ACE2 activity was measured with commercial kits. Patient data from the COVID-Hep and SECURE-Liver registries were compared using propensity score matching. Results: FXR activation directly upregulated ACE2 transcription in organoids from COVID19 affected tissues, including the biliary, gastrointestinal and respiratory systems. Conversely, FXR antagonism with z-guggulsterone or UDCA, had the opposite effect. Importantly, both drugs reduced susceptibility to SARS-CoV-2 infection in lung, cholangiocyte and gut organoids. Furthermore, systemic administration of UDCA in human organs perfused ex-situ downregulated ACE2 and reduced SARS-CoV-2 infection ex-vivo. Oral UDCA rapidly reduced serum ACE2 in vivo. Registry data showed a correlation between UDCA administration and better clinical outcomes in COVID19 patients, including hospitalisation, ICU admission, mechanical ventilation and death. Conclusion: We discovered FXR as a novel therapeutic target against SARS-CoV-2 and we identified approved FXR inhibitors which could be repurposed to potentially treat COVID19, paving the road for future clinical trials to validate these results.

Fxr antagonists as new agents for COVID19

Introduction The management of COVID19 is complicated by vaccine availability, the modest efficacy of existing treatments, and the potential for viral resistance. Therefore, there is a pressing need for new prophylactic and therapeutic agents. The viral receptor ACE2 is an ideal target as it is required for SARS-CoV-2 entry in host cells. Modifying ACE2 expression could prevent infection and/or limit disease progression. Nevertheless, the mechanisms controlling ACE2 expression remain elusive. Aims To identify pathways controlling the transcriptional regulation of ACE2, and exploit them to reduce SARS-CoV-2 infection. Methods Organoids from primary biliary, intestinal and pulmonary epithelia were derived and cultured as previously described. Single-cell RNA sequencing, QPCR, immunofluorescence and flow cytometry were used to assess marker expression. Chromatin immunoprecipitation was used to assess FXR binding on DNA. Bronchoalveolar lavage SARS-CoV-2 patient isolates were used for infection experiments. Human livers not used for transplantation were connected to the metra (OrganOx) normothermic perfusion device and perfused ex-situ using therapeutic doses of UDCA for 12 hours. ACE2 activity was measured following manufacturer's instructions. Patient data from the COVID-Hep and SECURE-Liver registries were compared using propensity score matching for sex, age and Child-Turcotte-Pugh score. Results We first demonstrated that cholangiocytes are susceptible to SARS-CoV-2 infection in vivo and in organoid culture. We then used cholangiocyte organoids to identify FXR as a transcriptional regulator of ACE2. We validated our results in pulmonary and intestinal organoids, showing that ACE2 regulation by FXR represents a broad mechanism present in multiple COVID19-affected tissues. We then demonstrated that approved FXR inhibitors, such as ursodeoxycholic acid (UDCA) and z-guggulsterone (ZGG), decrease ACE2 levels and reduce viral infection in vitro in primary biliary, intestinal and pulmonary organoids. We interrogated the impact of systemic UDCA administration in human livers perfused ex-situ, demonstrating reduced ACE2 levels and SARS-CoV-2 infection. Furthermore, we showed that commencing UDCA treatment lowers ACE2 levels in primary biliary cholangitis (PBC) patients. Finally, we identified a correlation between UDCA treatment and better clinical outcome in COVID-19 patients, including hospitalisation, ICU admission, mechanical ventilation and death, using registry data. Conclusion We identified FXR as a novel master regulator of ACE2 expression. Using a bench-to-bedside approach we combined in vitro, ex-vivo and patient data to demonstrate the efficacy of ACE2 downregulation against SARS-CoV-2 infection and identified approved and inexpensive drugs (UDCA, ZGG) which could be repurposed as prophylactic and therapeutic agents against SARS-CoV-2 infection, paving the road for future clinical trials.

Chaos, Care, and Critique: Performing the Contemporary Academy During the COVID-19 Pandemic

The starting point for this article is that the COVID-19 global pandemic has brought normally invisible, taken-for-granted aspects of contemporary societies into sharp relief. I explore the analytical affordances of this moment through a focus on the nature of the contemporary academy, asking how this was performed on "academic Twitter" in the early months of the 2020 COVID-19 pandemic, therefore contributing to work that has characterized contemporary university, research practice, and social media discussion of this. I draw on a dataset of tweets from academic Twitter, systematically downloaded between 1 March and 24 July 2020, that are concerned with the pandemic, analyzing these through a qualitative, multimodal, and practice-oriented approach. I identify themes of the disruption of academic work, of care and care practices, and of critiques of injustice and inequity within academia, but also argue that the ways in which these topics are instantiated-through distinctive repertoires of humor and of emotional honesty, positivity, and gratitude-are central to performances of academic life. The analysis thus further contributes to studies of communication to and by other publics, and in particular, the ways in which the content and form of social media communication are intertwined.

Blowing bubbles: COVID-19, New Zealand’s bubble metaphor, and the limits of households as sites of responsibility and care

When New Zealand embarked on its COVID-19 lockdown, the world saw the emergence of a new social form: the “bubble.” This chapter examines bubbles for the social dynamics they enabled and elided, as well as for what the bubble metaphor suggested but did not always deliver. During level 4 lockdown, most New Zealanders (with exceptions such as essential service workers) were restricted to physical contact with members of their residence - a social unit the government referred to as the members of one’s “home, " “household, " or “bubble.” Not all care relations can, however, be reduced to a single home or household, nor are all households units of care. Regulations enabling bubble expansions in specific circumstances provided some means of addressing care needs that superseded households (e.g., singletons becoming “bubble buddies” to mitigate loneliness). But little was done for those consigned to bubbles whose members were unattached to one another, much less antagonistic. There is thus a need for bubble regulations to match more closely the flexibility inherent in the bubble as a concept when planning for future crises. © 2021 selection and editorial matter, J. Michael Ryan;individual chapters, the contributors.